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CONCERNING  SOME 

HEADACHES  AND  EYE  DISORDERS 

OF  NASAL  ORIGIN 


CONCERNING  SOME 

HEADACHES  AND  EYE   DISORDERS 
OF  NASAL  ORIGIN 


BY 

GREENFIELD  SLUDER,  M.D. 

CLINICAL    PROFESSOR    AND    DIRECTOR    OF    THE    DEPARTMENT    OF    LARYNGOLOGY    AND 

RHINOLOGY,   WASHINGTON   UNIVERSITY   MEDICAL   SCHOOL, 

ST.    LOUIS. 


WITH  115  ILLUSTRATIONS 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1918 


Copyright,  1918,  By  C.  V.  Mosby  Company 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


Bioraedied 
Library 

wv 

i60 


111? 


TO  THE  MEMORY  OF 

JOHN  BATES  JOHNSON,  M.D.  (HARVARD) 

PROFESSOR   OF   MEDICINE  IN   THE    ST.   LOUIS 

MEDICAL  COLLEGE   (LATER  THE  MEDICAL 

DEPARTMENT     OF     THE     WASHINGTON 

UNIVERSITY)     FROM     1853     TO     1903. 

WHOSE  ERIENDSHIP  HAS  BEEN  INSPIRATION 
AND  STRENGTH  THROUGHOUT  MY  LIFE 


PKEFACE 

My  interest  in  the  subject  matter  of  these  pages  com- 
menced in  1894  Avhen  my  friend  Dr.  Arthur  E.  Ewing  began 
what  was  to  be  a  convincing  argument,  that  the  ''asthenopics'^ 
delineated  in  Chapter  I  were  really  not  eye  cases  but  '^nose 
cases  of  some  kind  not  yet  understood,"  It  is  therefore  easy  to 
understand  a  deep  sense  of  gratitude  and  obligation  on  my  part 
for  not  only  the  novel  idea  but  the  material  for  the  study  and 
determination  of  the  underlying  facts.  It  resulted  in  my  be- 
coming a  rhinologist  and  abandoning  internal  medicine  for 
which  I  had  made  elaborate  (ten  years)  preparation.  Very 
early  were  added  the  influence  of  my  friends  Dr.  M.  H.  Post 
and  Dr.  John  Green  to  the  argument  of  Dr.  A.  E.  Ewing,  all 
renoAATied  ophthalmologists.  From  then  until  now  my  interest 
in  the  nasal  factors  of  headaches  and  eye  lesions  has  been  deep 
and  constant.  During  these  years  much  has  been  written  on 
this  dual  subject,  a  complete  bibliography  of  which  would  serve 
little  or  no  purpose  for  the  present  text,  aside  from  the  labor 
of  supplying  it. 

The  suppurative  nasal  diseases  have  been  learnedly  pre- 
sented by  Dr.  Ludwig  Gruenwald  in  Die  Lehre  der  Naseneiter' 
ungen  1892,  and  later  elaborated  and  much  valuable  informa- 
tion added  thereto  by  Dr.  Marcus  liajek  in  Die  enfzundliclie 
Erhrankungen  der  NehenJioelen  der  Nase,  1899.  To  Doctor 
Hajek  as  my  teacher — 1896  to  1898 — I  owe  a  great  debt  of  grat- 
itude. I  soon  learned  however  that  the  cessation  of  the  nasal 
suppuration  was  not  always  the  cure  of  the  case  b}^  any  means. 
In  the  effort  to  solve  the  questions  for  such  patients  the  tis- 
sues removed  from  their  noses  Avere  submitted  in  vain  to  many 
pathologists,  some  of  them  heing  the  most  ronoAAnied  of  their 
day.  They  remained  a  closed  secret  imtil  1909  when  I  pre- 
sented the  specimens  to  Dr.  Jonathan  Wright.  He  at  once  read 
the  story  from  the  tissues  presented  by  virtue  of  his  learning 
as  a  rhinologist  combined  with  that  of  the  pathologist  (a  rare 
combination).    It  will  therefore  be  easy  to  understand  my  deep 


10  PREFACE 

obligation  and  gratitude  to  Doctor  Wright  for  this  inestimable 
service,  in  which  I  feel  that  both  rhinologists  and  ophthalmol- 
ogists should  unite.  He  has  been  good  enough  to  furnish  me 
with  a  summary  of  the  general  remarks  he  has  had  to  make  in 
our  discussions  of  the  subject  now  extending  over  a  period  of 
a  number  of  years  and  has  illustrated  the  points  he  has  wished 
to  emphasize  by  a  number  of  drawings.  This  material  I  have 
employed  as  an  introduction  to  the  pathological  aspects  of  the 
subject. 

Some  macroscopic  anatomical  observations  will  also  be 
found  here.  In  large  part  I  am  indebted  to  my  friend  Dr.  Eob- 
ert  J.  Terry,  Professor  of  Anatomy,  Washington  Medical 
School,  St.  Louis,  Mo.,  for  much  of  the  material  upon  which 
these  observations  were  made.  They  date  from  1898  when  I 
began  observations  on  the  sections  of  decalcified  skulls.  From 
then  until  now  I  have  recorded  no  anatomical  conclusions  with- 
out consultation  A^th  Doctor  Terry.  It  is  with  great  pleasure 
that  I  acknowledge  this  debt,  no  mention  of  which  heretofore 
has  had  his  permission. 

During  the  winters  of  1896  and  1897  it  was  my  privilege  to 
be  a  student  in  the  Physiological  Laboratory  of  the  University 
of  Vienna  under  the  guidance  of  Professor  Sigmund  Exner. 
There  I  was  given  cliance  for  much  elementary  study  of  the 
nose  and  throat  and  witnessed  much  research  upon  the  lar^mx. 
I  was  also  guided  in  some  research  efforts.  I  feel  that  that 
opportunity  Avas  a  most  fortimate  one.  It  had  much  to  do 
with  establishing  my  point  of  view  which  in  large  part  has 
finally  crystallized  out  in  the  observations  here  recorded. 
From  then  until  now  I  have  ever  borne  Professor  Exner  a  deep 
feeling  of  gratitude  and  affection  for  his  kindness,  generosity, 
patience  and  Avise  guidance. 

Greenfield  Sluder. 

St.  Louis,  Mo.,  U.  S.  A. 
June  1,  1918. 


CONTENTS 


PAGE 

Introduction  to  the  Pathological  Anatomy,  by  Dr.  Jonathan  Wright     .  17 

The  Nose. — -A  General  Consideration 25 

Headaches  in  General 27 

Headaches  of  Nasal  Origin 29 

Megrim 29 

Ohapter  I. — Vacuum  Frontal  Headaches  with  Eye  Symptoms  Only     .     .  30 

Clinical  Picture 32 

Ewing's  Sign 32 

Gross  Etiology 34 

Anatomy  of  the  Middle  Meatus 35 

Pathology  and  Method  of  Closure 47 

Differential   Diagnosis 53 

Headaches  from  all  Causes  and  their  Differentiation 54 

Prognosis 54 

Treatment 54 

Vacuum  Ethmoidal  Headaches,  with  Eye  Symptoms  Only 56 

Vacuum  Maxillary  Antrum  Headaches 56 

Ohapter  II. — The  Syndrome  of  Nasal  (Sphenopalatine — Meckel's)  Gan- 
glion Neurosis 57 

Anatomy  of  the  Nasal  Ganglion 57 

Topographical    Anatomic    Relations 61 

To  the  Nose  and  Paranasal  Cells 61 

In   the   Sphenomaxillary   Fossa 64 

To  the  Walls  of  the  Cells 65 

To  the  Lateral  Wall  of  the  Nose 'i'^ 

Clinical  Relations 66 

The  Neuralgic  Syndrome  with  the   Usual   Forerunner 69 

The  Sympathetic  Syndrome 70 

Diagnosis ^8 

Differential  Diagnosis 79 

Prognosis 79 

Treatment 82 

Anatomic  Considerations 82 

Instrumentariuni 89 

Technique ^0 

<;;hapter  III. — Hyperplastic  Sphenoiditis  and  Its  Clinical  Relations  in 
THE  Environing  Nerves;  Namely,  the  Optic,  Oculomotor 
Troclear,  Trigeminus,  Abducens  and  Vidian  (N.  Canalis 

Pterygoideus)  Nerves  and  the  Nasal  Ganglion     ....  96 

11 


12  CONTEXTS 

Anatomical    Relations 97 

Clinical  Relations Ill 

Differentiation    of    Nasal    Ganglion    Neurosis    from    the    Syndrome    of 

Hyperplastic   Sphenoiditis 112 

Dr.  Jonathan  Wright's  Observations 117 

Dr.  Ladilaus  Onodi's  Observations 124 

Explanation  of  the  Headaches  and  Eye  Disorders.     Clinical  Difference 

Between  the  Nerves  in  the  Canals  and  the  Sphenoidal  Tissue  127 

The  Lesion  in  Children 128 

Postoperative  Results  and  the  External  Skull 129 

Dr.    Jonathan    Wright 's    Conclusions ]  29 

Diagnosis 131 

Source    of    Light 131 

The  Normal  Post-ethmoidal-sphenoidal  District 133 

Distril)ution    of    the    Morbid    Process 134 

Hyperplastic  Post-ethmoiditis 135 

Polyp  Formation 136 

The  Wiping  Action  of  the  Soft  Palate 137 

Oblique  Hlumination  of  the  Epithelium 138 

Transference  of  Pus 140' 

Signiticance   of   Unilateral    Lesion 140 

The  Subdivided  Sphenoid  Body  and  Its  Diagnosis 142 

The  Inequality  in  the  Two  Sphenoid  Cells  and  Its  Clinical  Importance  145 

Diagnosis    in    Children 145 

Prognosis 149 

Treatment 152 

Surgery  of  the  Paranasal  Cells 154 

Nerve-trunk   Anaesthesia 160 

The  Operative  Procedure 162 

Maxillary  Sinus   Surgery 185 

Case    Histories       192 


ILLUSTRATIONS 

FIG.  P-^CiE 

1.  Osteoblasts 18 

2.  Hyperplasia  of  bone  of  splieiioothnioidal  wall 19 

3.  Papillary  hypertropliy  of  mucous  meJiibrane  of  sphenoidal  sinus — rarefying 

osteitis 20 

4.  Rarefying   osteitis 21 

5  Chronic    hypertrophy    of    middle    turljinate    body 22 

6.  Chronic    hypertrophy    of    middle   turbinate    body 23 

7.  Showing  where  needle  has  been  passed  through  the  floor  of  the  frontal  sinus  30 

8.  Showing  a   dissection   of   the   right   orbit   from   above 31 

9.  Showing  a  needle  passed  from   frontal   sinus 33 

10.  Showing  hiatus   semilunaris   infundibulum   and   frontal   sinus    in    direct   and 

uncomplicated  connection 36 

11.  Showing  ethmoid  cell  entering  infundiliulum  from  above  and  behind     ...  36 

12.  Showing  ethmoid  cells  entering  infundibulum   and  hiatus   semilunaris  from 

above   and   below   in   front 36 

13.  Showing  ethmoid   cells   entering  infundibulum   and   hiatus   semilunaris   from 

above  in  front  and  behind  and  below 36 

14.  Showing    hiatus    semilunaris    ending    in    blind    pocket    aliovc    infundiliulum 

limited  above  by  roof  of  nose 37 

15.  Bristle  passed  from  frontal  sinus  into  hiatus  semilunaris 37 

16.  Showing  ethmoid  cells  opening  into  hiatus  semilunaris 37 

17.  Showing  hiatus  semilunaris  ending  in  blind  pocket  above 37 

18.  Roentgenograms  showing  hiatus  semilunaris  situated  unusually  far  back     .     .  38 

19.  Amputation   of  middle   turbinate  with   the   line   of   origin   from   the   lateral 

wall.     Cavernous  tissue  on  the  internal  aspect  of  frontal  pouch     ...  39 

20.  View  of  lateral  wall  showing  what  appears  to  be  normal  conditions     ...  40 

21.  View  of  lateral  wall  showing  total  absence  of  cavernous  tissue.     Otherwise 

apparently  normal ■il 

22.  Showing  middle  turbinate  detached  in  its  anterior  two-thirds  and  turned  up 

at  bulla  ethmoidalis 42 

23.  Bulla  ethmoidalis  in  contact  with  processus  uncinatus 42 

24.  Septum  showing  well-marked  tubercle  and  deeply  marked  imprint  of  entire 

middle   turbinate         43 

25.  Sagittal    section   showing   relations   of   middle   turbinate   to   tlie    tuliercle   of 

the  septum 44 

26.  Showing  middle  turbinate  placed  with  free  space  between  septum  and  lateral 

wall 45 

27.  Showing  septum  well  marked  almost  like  spur  at  the  site  of  its  tubercle     .  46 

28.  Showing  posterior  spur  and  well-marked  ridge  with  large  tubercle     ....  47 

29.  Cross    section   in    posterior    part    of    nose    showing    spurs    above    aiul    lielow 

middle    turljinate         48 

30.  Wood's  metal  casts  of  a  narrow  middle  meatus 51 

31.  Wood's  metal  casts  of  a  wide  middle  meatus 51 

13 


14  ILLUSTRATIONS 

FIG.  PAGE 

32.  Wood's  metal  cast  of  a  wide  middle  meatus  with  very  wide  frontal  and 

ethmoidal    pouches 52 

33.  Wood's  metal   cast  of   a  wide  middle   meatus   with  very  wide   frontal   and 

ethmoidal  pouches 52 

34.  Showing  nasal  ganglion,  Vidian  nerve,  and  nasal  palatal  branches     ...  59 

35.  Showing  sphenopalatine  foramen  bounded  above  by  sphenoidal  sinus   and 

in  front  by  ethmoidal  cells 62 

36.  Sagittal  section  7  mm.  lateral  to  the  sphenopalatine  foramen 63 

37.  Showing  left   sphenoidal   sinus   prolonged   downward   to   form   the   anterior 

wall  of  the  sphenomaxillary  fossa 64 

38.  Showing   anatomy   of   the   nasal    ganglion 65 

39.  Showing  anterior  face  of  right  pterygoid  process 66 

40.  Sagittal  section  3  mm.  lateral  to  the  sphenopalatine  foramen 67 

41.  Showing  middle  turbinate  and   sphenopalatine   foramen 68 

42.  Showing  pterygoid  process  projecting  forward  beyond  the  posterior  limit 

of   sphenopalatine   foramen        83 

43.  Showing  usual  sphenopalatine  foramen 84 

44.  Showing   correct   placing  of   needle        .  85 

45.  Showing  both  straight  and  curved  needles  correctly  placed 86 

46.  Showing  nasal  ganglion  needle  having  passed  across  the   sphenomaxillary 

fossa  and  then  through  the  thin  wall  of  a  low  set  sphenoidal  sinus     .  87 

47.  Showing  needle   transfixing   the   middle   turbinate 88 

48.  Showing  needle  having  passed  across  the  sphenomaxillary  fossa     ....  91 

49.  Straight   needle        92 

50.  Left  sagittal  section  5  mm.  lateral  to  s2)henopa]atine  foramen  showing  post- 

ethmoidal  cell  above  and  beyond  optic  nerve 96 

51.  Showing   prolongation   of   sphenoidal   sinus   around   optic    canal     ....  97 

52.  Anterior  and  middle  fossae  of  skull  seen  from  above 98 

53.  Showing  an  older  representation  of  the  sphenoidal  sinus  and  the  cavernous 

sinus        99 

54.  Cross  transverse  section  of  the  cavernous  sinus 99 

55.  The  usual  cavernous  sinus  with  large  cross  section  and  great  length     ...  99 

56.  Cavernous  sinus  district 99 

57.  Cavernous  sinus  district  showing  foramen,  cavernous  sinus,  and  crista  galli  100 

58.  Left  middle  fossa  of  skull  showing  foramen  ovale  separated  from  sphenoidal 

sinus    by    thin    bone 100 

59.  Showing  foramen  rotundum,  bone   separating  sphenoid   cell   from   foramen 

rotundum           100 

60.  Top  view  of  left   sphenoidal   district   dissected 101 

61.  Shows  a  sagittal  section  of  left  side  through  the  ophthalmic  nerve     ....  102 

62.  Sphenoidal  cell  showing  columnar  marking  of  the  internal  carotid  artery     .  103 

63.  Showing  Vidian   exposed  in   sphenoid   sinus 104 

64.  Left  Vidian  canal  deficient  at  point  of  indicator 105 

65.  Right   sphenoid   cell 105 

66.  Showing   paper-thin   separation   of   maxillary   nerve   in   foramen   rotundum 

from  sphenoid   sinus 106 

67.  Cross  section  just  anterior  to  anterior  clinoid  process 106 

68.  Cross   section        106 


ILLUSTRATIONS  15 

FIG.  PAGE 

69.  Cross  section  of  sphenoid  body  througli  anterior  clinoid  process  posterior 

to  optic  canals 107 

70.  Lateral  part  of  sagittal  section  through  line  10  of  Fig.  69 107 

71.  Sagittal  section  between  the  foramen  rotundum  and  Vidian  canal  right  side  108 

72.  Sagittal  section  of  specimen  shown  in  Fig.  73 109 

73.  Showing  the  nasal  (internal)  surface  of  specimen 110 

74.  Sagittal  section  between  foramen  rotundum  and  Vidian  canal,  viewed  from 

without  Ill 

75.  Showing  a  cell  which  appeared  to  be  the  sphenoidal  cell 140 

76.  Same  as  Fig.  75  showing  probe  in  lower  cell.     Upper  cell.    Sella  turcica     .  141 

77.  Showing  an  upper  and  lower  subdivision  of  the  sphenoid  body     .     .     .     .  142 

78.  Showing  an  anterior  and  posterior  subdivision  of  the  sphenoid  body     .     .  143 

79.  Showing  subdivided   sphenoid   body 144 

80.  Showing  probe  in  large  undivided  sphenoid  body 145 

81.  Shows   probe   introduced   into   a   very  large   sphenoidal   cell   downward   to 

the  bifurcation  of  the  plates 146 

82.  Same  as  Fig.  81  taken  from  in  front 147 

83.  Eight  sphenoidal  sinus  extending  into  left  side  to  border  left  optic  canal  148 

84.  Two  views   of   palate   hook 148 

85.  Sluder's  upper  cell  operation.     Two  views  of  the  angle  knife 165 

86.  Sluder's  upper  cell  operation.     Shows  the  angle  knife  introduced  between 

the  septum  and  middle  turbinate 167 

87.  Sluder's  upper  cell  operation.     Same  as  Fig.  86,  the  knife  has  been  passed 

a  second  time  along  the  cribriform  plate 168 

88.  Sluder's  upper  cell  operation.     Knife  introduced  sagitally  under  the  middle 

turbinate 169 

89.  Sluder's  upper  cell  operation.     Shows  the  snare  loop  placed  aroimd  part 

detached 170 

90.  Sluder's  upper   cell   operation.      Showing   the  line   of   amputation   of   the 

pendulous    middle    turbinate 171 

91.  Sluder's  upper  cell  operation.     Shows  knife  passed  backward  along  cribri- 

form   plate 172 

92.  Sluder's  upper   cell   operation.      Shows   knife   to   have   been   reintroduced 

through  uppermost  part  of  sphenoidal  cut 173 

.93.  Sluder's    upper  cell  operation.     Shows  the  Knight  forceps  introduced  into 

the  anterior  face  of  the  sphenoid  bodj' 174 

94.  Sluder's  upper  cell  operation.     Shows  the  Knight  forceps  in  position  to 

bite  out  the  post-ethmoidal  wall  which  has  been  cut  loose 175 

95.  Sluder's   upper   cell   operation.      Shows   post-ethmoidal   wall   in   grasp   of 

forceps 176 

96.  Sluder's  upper   cell   operation.      Shows   a  three-quarter   view   of   specimen 

with   operation   completed 177 

97.  Sluder's  upper  cell  operation.     A  three-quarter  view  of  a  post-ethmoidal 

forceps  made  right  and  left 178 

98.  Sluder's  upper  cell  operation.     Sphenoid  and  turbinate  knives     ....     178 

99.  Sluder's  upper  cell  operation.     Shows  the  knife  in  position  for  cutting 

away  the  uncinate  process  preparatory  to  Ingals'  removal  of  the  fron- 
tal   sinus    floor 17J> 


16  ILLUSTRATIONS 

PIG.  PAGE 

100.  Shulor's  upper  eoll  opiM-atioii.     Shows  knife  approaching  a  post-ethmoidal 

cell  which  lies  on  the  top  of  the  sphenoidal  sinus  and  occupies  about 

one-half  of  the  body  of  the  sphenoid 180 

101.  Sluder's  upper  cell  operation.     A   shows  the  usual  sphenoidal   sinus   and 

the  usual  cribriform  plate  with  their  usual  relations.     B  shows  post- 
ethmoidal  cell  placed  altogether  on  top  of  sphenoidal  sinus     ....  181 

102.  Sluder's  upper  cell  operation.     Showing  right  sphenoidal  sinus  extending 

into  left  side  to  border  left  optic  canal 182 

103.  Sluder's  upper  cell  operation.     Sphenoidal  speculum 182 

104.  Sluder's  upper  cell  operation.     Showing  proportions  in  a  short  nose     .     .  183 

105.  Sluder's  upper  cell  operation.     Showing  proportions  in  a  tall  nose     .     .     .  184 

106.  Detached   lower   turbinate.      Opening  cut    into    antrum 187 

107.  Sluder's  intra-nasal  antrum  forceps 188 

108.  Technique  of   Sluder's  antrum   operation 189 

109.  Technique  of  Sluder's  antrum  operation 189 

110.  Technique  of   Sluder's  antrum  operation 190 

111.  Showing  lower  turbinate  replaced  to  original  position.   Opening  into  antrum  191 

112.  Eye  chart 254 

113.  Eye  chart 255 

114.  Eye  chart 256 

115.  Eye  chart      . 257 


CONCERNING  SOME 

HEADACHES  AND  EYE  DISORDERS 

OF  NASAL  ORIGIN 


AN  INTRODUCTION  REFERRING  TO  SOME  POINTS 

IN  THE  MINUTE  PATHOLOGICAL  ANATOMY 

OF  THE  PROCESS 

By  Jonathan  Wright,  M.D. 

The  drawings  illustrate  very  well  many  of  the  points  in  Dr. 
Slnder's  stndy  of  the  involvement  of  the  superior  accessory  si- 
nuses in  pathological  processes. 

As  a  rule  these  have  started  from  conditions  very  common 
in  the  nasal  passages.  Evidently  these  conditions  from  start 
to  finish  come  well  within  the  definition  of  chronic  infiannnation. 
So  far  as  the  bone  changes  are  concerned  the  pathological  con- 
dition is  directly  related  to  the  normal  processes  of  bone  growth 
in  the  nose  in  its  origin  and  throughout  its  whole  course. 

This  relationship  is  not  difficult  to  recognize.  In  the  ex- 
planation which  follows  I  only  pretend  to  arrange  them  in  se- 
quence and  to  make  application  of  certain  Avell-lvno^^^l  facts. 

This  explanation  may  appear  all  very  elementary  and  per- 
haps unsuitable  for  introduction  in  this  work.  I  have  however 
become  accustomed  to  look  upon  this  sort  of  inflammation,  and 
doubtless  there  are  numerous  other  examples  of  the  same  prin- 
ciple, as  dne  to  the  substitution  of  the  stimulus  of  irritation, 
whether  from  external  surface  agents,  from  bacterial  agents 
of  disease  within  the  surface  or  from  systemic  vasomotor  dis- 
orders, for  that  mysterious  physiological  stimulus  of  growth 
Avhich  carries  with  it  some  agency  which  shapes  the  symmetry 
of  form. 

In  the  pathological  processes  that  agent  which  shapes  the 
symmetry  of  form  is  absent  or  works  badly  and  we  get  un- 
symmetrical  development  in  the  hyperplastic  irregular  and  jDur- 

.17 


18  HEADACHES   AND   EYE    DISORDERS    OF    NASAL    ORIGHST 

poseless  cavities  in  the  rarefying  bone  processes  Avhicli  are  ex- 
emplified in  the  specimens. 

In  order  to  illnstrate  the  above  remarks,  which  sum  up  my 
understanding  of  the  nature  of  the  metabolism  of  bone  in 
health  and  in  disease  of  the  nasal  structure,  I  have  ventured  in 
one  figure,  made  up  of  a  series  of  three  sketches,  to  select  from 
material  other  than  that  left  by  Dr.  Sluder  in  my  hands. 

Fig.  1  consists  of  certain  parts  of  several  drawings  in  a 
work*  published  by  Doctor  Smith  and  myself.  I  have  taken 
these  out  to  illustrate  the  process  as  it  occurs  not  only  in  the 
embryo  and  in  early  uterine  life,  but  in  the  bone  processes  of 
chronic  inflammation  of  the  bony  structure  of  the  nose. 

In  the  embryo  and  in  the  normally  developing  child  and 
in  the  young  adult  this  bone  process  is  responsible  for  the  hol- 
lowing out  and  the  shaping  of  the  various  accessory  cavities 


Fig.   1. — Composite    drawing    from    Wright    and    Smith.      A.  Osteoblasts    depositing    bone    salts. 
B.  Transition    stage.       C.  Osteoclast    absorbing    bone    salts. 

of  the  nose  and  it  is  also  responsible  for  the  maps,  so  to  speak, 
of  the  turbinated  bones,  as  they  appear  in  transverse  section. 
In  Fig.  1  it  will  be  observed  that  A  represents  an  edge 
of  bone  lined  with  ovoid  cells,  or  osteoblasts,  which  are  deposit- 
ing lime  salts  in  the  formation  of  the  bone  structure.  Much  of 
the  finer  structure  of  all  these  sections  has  been  destroyed  by 
a  decalcif^dng  process.  In  the  drawing  B  a  locality  has  been 
chosen  where  the  ovoid  cells,  or  osteoblasts,  are  being  grouped 
together;  but  thej  have  not  as  yet  lost  the  outlines  of  their 
limiting  individual  cell  membranes.  They  are  grouped  together 
so  that  their  peripheries,  or  external  cell  membranes,  are  touch- 
ing one  another.  Subsequent!}^,  over  the  area  of  the  surfaces 
which  touch  one  another,  these  limiting  membranes  disappear, 
the  cell  bodies  are  throAA^l  into  one;  and  out  of  several  mono- 

*Wright,   Jonathan,    M.D.,   and    Smith,    Harmon,    M.D. :      A    Textbook   of   the    Diseases    of 
the  Nose  and  Throat,  New  York,   Lea  &  Febiger,   1914. 


INTRODUCTIOjST 


19 


nuclear  osteoblasts,  Ave  have  one  large  mnltinuclear  giant  cell, 
or  osteoclast,  shown  in  the  drawing  C. 

With  this  change  in  cell  form,  brought  about  by  a  coali- 
tion, there  results  a  change  in  the  metabolism.  The  process  is 
reversed.  Bone  salts  are  absorbed  in  place  of  being  precipi- 
tated. "Wliat  chemical  change  in  the  cells  induces  this  reversal, 
it  may  be  less  difficult  to  imagine  than  the  biological  change 
which  initiates  it  and  of  which  the  chemical  change  is  only  a 


U 


Fig.  2. — Hyperplasia  of  bone  of  sphenoethmoidal  wall.     (X  200,  camera  lucida.) 


part.  It  is  fair  to  assume  that  it  is  the  physiological  bone  proc- 
ess by  wiiich  nature  shapes  the  framework  of  the  body;  but 
evidently  there  are  other  ways  of  giant  cell  formation,  one  of 
which  is  shown  in  Fig.  4. 

In  the  material  Doctor  Sluder  has  left  with  me,  I  select  that 
from  the  case  of  E.  II,  G.,  which  consists  of  pieces  of  the  post- 
ethmoidal  wall,  to  show  in  Fig.  2,  a  hyperplastic  bone  process. 


20 


HEADACHES    AjSTD    EYE    DISORDERS    OF    NASAL    ORIGIN 


AVhile  other  localities  in  the  same  material  show  other  con- 
ditions, it  is  strikingly  evident  we  have  here  a  thickening-  of 
the  bone.  The  osteoblasts,  not  sliown,  of  conrse,  in  the  low- 
power  magnification,  ])eneath  a  thickened  epithelinm,  have  bnilt 
up  a  solid  wall  of  bone.  If  Ave  turn  now  to  the  tissue  from  the 
sphenoidal  wall  of  Ed.  D.,  we  find  that  a  rarefying  osteitis 
represented  in  Fig.  3,  has  been  at  work,  perhaps  in  bony  tissue 
which  had  been  formed  in  the  condition  we  have  studied  in  Fig. 
2.  It  is  possible  that  the  duration  of  the  sinus  diseases  may 
have  been  longer  in  the  Ed.  D.  case  (Fig.  3)  than  in  the  E.  II.  G. 


-^S^^-^OWS!?^^ 


*^- 


-^  ASAL 

.    'w'A  L 


PAPILLARY   HYPERTROPHY  OF  RAPEFYINS   05TE1TI5 

MUCOUS    MEMBRANE,  or  5PHE:N01D  SINUS 

Fig.    3.  —  (X    10,    camera   lucida. ) 


case  (Fig.  2),  but  that  is  not  necessarily  so.  We  perceive,  how- 
ever, in  Fig.  3,  the  papillajy  hypertrophy  of  the  mucous  mem- 
brane lining  the  cavity,  which  is  so  conunon  in  these  old  cases, 
usually  suppurative,  of  sinus  disease. 

The  drawings  (Figs.  2  and  3)  have  been  made  with  camera 
lucida,  from  appearances  under  very  low  magnifications. 

I  select  from  the  case  of  Mrs.  L.  E.,  a  field  (Fig.  4),  made 
under  high  magnification,  admirably  adapted  to  act  as  a  com- 
panion piece  to  the  partially  schematic  drawings  in  Fig.  1.    A 


INTRODUCTTOX  21 

careful  study  of  it  will  reveal  a  ininil)er  of  osteoclasts,  or  ciant 
cells,  varying-  from  indeternuiiate  biiiiiclear  affairs  up  to  the 
large  nmltiiinelear  cell  seen  in  close  juxtaposition  to  the  edge 
of  the  bone. 

This  cluster  of  osteoclasts  seems  to  have  indented  the 
surface  of  the  bone  by  virtue  of  their  lione-absorbing  func- 
tions. In  the  normal  process  of  cavity  formation,  the  sinuses 
grow  in  capacity  by  virtue  of  this  activity  of  the  osteoclasts. 


Fig.   4. — Rarefying   osteitis.      (V12   0.    imm. )       Showing  action    of   osteoclasts. 

In  almost  the  same  locality  of  a  single  specimen  of  the  patho- 
logical process,  we  may  have  both  this  absorption,  or  osteoclastic 
activity,  and  the  bone-forming,  or  osteoblastic  activity  going  on. 
Where  the  bone  formation  along  one  surface  goes  on  at  the 
same  time  that  bone  absorption  goes  on  along  the  other  surface 
of  the  anterior  part  of  the  middle  turbinate  bone,  we  occasionally 
get  the  formation  of  a  bony  cyst.  I  have  remarked  that  the 
method  of  osteoclast,  or  giant  cell  formation,  as  exhi1)ited  in  Fig. 
1,  is  not  always  the  apparent  method  of  genesis.     Occasionally 


22 


HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


the  evidence  suggests,  as  it  does  here  in  Fig.  4,  that  the  giant 
cell  grows,  not  by  apposition  of  separate  cell  bodies,  bnt  by  the 
multiplication  or  proliferation  of  nuclei,  beginning  in  a  single 
cell. 

It  now  remains  for  me  to  show  in  Figs.  5  and  6,  draAvn 
from  the  specimen  of  the  middle  turbinate  bone  of  Miss  F.  P., 
how  this  bone  process  starts  as  a  sequence  of  an  ordinary  hyper- 
plasia of  the  mucous  membrane  of  a  turbinate  body.  In  Fig. 
6,  you  mil  see  this  typical  hypertrophy  represented  under  the 


Fig.  5. — Chronic  hypertrophy  of  middle  turbinate  body.  (X  10,  camera  lucida).  A.  B. 
Showing  osteophytic  growth.  C.  Fibrous  hyperplasia  at  points  from  which  Fig.  6  was  made 
with  high  power. 

high  power  at  a  point  (C)  selected  from  the  structure  shown 
under  low  power  in  Fig.  5.  There  is  only  one  thing  ex- 
ceptional in  the  picture  presented  by  the  latter.  You  Avill  see 
at  A  and  B  an  osteophytic  process  starting  at  the  edges  of 
the  middle  turbinate  bone,  Avith  suggestions  of  the  existence  al- 
ready in  the  newly  formed  low-grade  bone  of  a  rarefying  proc- 
ess. Now  this  new  activity  is  representative  of  how  a  tissue 
change,  which  we  know  begins  in  the  soft  parts,  inaugurates  a 


INTRODUCTION 


23 


tissue  change  in  bone,  whicli  when  arising  in  a  locality  chan- 
nelled by  sensitive  nerves  or  nerves  of  special  sense,  leads  to 
distressing  symptoms  and  grave  consequences ;  but  on  a  middle 
turbinate  bone  hanging  free  in  a  nasal  cavity,  nothing  of  vital 
importance  usually  results. 

In  Dr.  Sluder  's  cases,  then,  it  is  not  the  specificity  of  patho- 
logical activity  Avhich  engages  our  clinical  attention,  but  the 
specificity  of  locality. 


Fig.  6. — Chronic  hypertrophy  of  middle  turbinate   body.      (X   500.)      Taken  from  a  section  shown 

in  Fig.  5  at  C.  / 

It  would  probably  be  difficult  to  find  an  adult  individual 
in  temperate  or  cold  climates  who  does  not  iDresent  an  example 
of  this  bone  change  within  his  nasal  chambers,  which  we  have 
a  right  to  call  pathological.  It  is  only  exceptionally  that  the 
symptoms  to  which  it  gives  rise  are  sufficient  to  cause  him  to 
seek  relief.  When,  however,  it  causes  bony  occlusion  of  a 
nasal  fossa  by  means  of  a  spur  or  deviation,  when  it  stops  up 


24  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

the  ostiiiiii  of  an  accessory  nasal  sinns  and  prevents  proper 
drainage,  wlien  it  impinges  on  a  branch  of  a  sensitive  nerve  or 
involves  its  peripheral  distribution,  marked  symptoms  and  a 
long  train  of  the  consequences  may  ensue,  which  Dr.  Sluder 
describes. 

When  in  the  walls  of  the  sphenoidal  or  ethmoidal  sinus 
there  is  involvement  of  the  optic  nerve,  in  so  far  as  it  depends 
on  bony  pressure,  'olindness,  partial  or  complete,  is  pretty  sure 
to  occur.  When,  however,  the  alarming  symptoms  of  optic  in- 
volvement are  recent  and  slight,  the  trouble  raeij  not  be  due  to 
a  bony  pressure,  but  to  a  pressure  of  soft  parts,  or  to  an  ex- 
tension of  their  inflanunation  or  of  their  vascular  congestion. 
These  latter  conditions  may  be  relieved  l)y  giving  free  drainage 
and  ventilation  to  an  occluded  sinus ;  ])ut  in  an  inaccessible 
region,  if  there  is  pressure  of  a  bony  surface,  such  as  the  swell- 
ing, in  Fig.  2,  upon  a  sensitive  or  an  optic  nerve,  it  is  difficult 
to  see  how  the  symptoms  are  to  be  relieved.  Fortunately,  there 
is  good  reason  to  believe  that  in  the  nature  of  things,  the  en- 
croachment of  the  field  of  engorgement  and  soft  hyperplasia 
upon  tlie  nerve  structures  gives  a  timely  warning  so  that  sur- 
gical interference  is  possible  before  an  irreparal)le  condition 
results. 

It  is  perhaps  well  to  remark  tluit  we  have  sought  some  ob- 
jective evidence  of  infiammation  spreading  along  the  sheath  of 
the  optic  nerves  from  the  foci  of  inflammation  in  tlie  sinuses. 
Though  there  is  clinical  reason  to  suppose  this  sometimes  oc- 
curs, we  have  not  as  yet  secured  objective  proof  of  it  in  the 
material  at  our  disposal. 


THE  NOSE 

A  General  Consideration 

The  nose  seems  to  me  an  anatomical  and  clinical  region 
that  has  special  features  to  be  considered  (that  are  self-evident 
as  soon  as  thonght  is  directed  to  them)  which,  so  far  as  I  know, 
have  not  been  emphasized  even  in  this  day  of  liighly  specialized 
specialties. 

First,  the  nose,  as  the  most  protrudiiig  fcMture  of  the  face,^ 
is  exposed  to  injury  far  more  than  the  rest  of  the  face,  as  has 
often  been  remarked.  Falls  and  blows  readily  injure  the  nose, 
that  do  not  harm  the  eyes  or  teeth;  and  probably  during  birth 
the  nose  is  often  injured  despite  its  then  elastic,  pliable  con- 
sistency. This  seems  the  only  etiology  for  th(^  dislocation  of 
the  anterior  part  of  the  septum  from  the  V  of  the  wings  of  the 
premaxillary  bones,  giving  rise  to  a  deflected  septum  in  pa- 
tients who  have  never  had  an  injury.  Mosher^^  has  given  us 
this  anatomy  comprehensively.  A  slightly  deflected  septum 
may  seem  clinically  negligible,  but  later  in  life  give  rise  to  the 
low  grade  vacuum  headache  with  asthenopia. 

Second,  in  the  human  being  the  nose  has  two  paranasal 
cells  that  have  no  gravity  drain,  to  wit,  the  maxillary  antrum 
and  the  sphenoidal  cell,  which  is  a  great  disadvantage.  To 
these  may  be  added  possibly  some  of  the  ethmoid  cells.  In- 
fection in  these  cells,  which  leads  to  suppuration,  is  therefore 
less  apt  to  subside  spontaneously  than  in  the  fi'ontal  sinus  when 
the  outlet  (or  inlet)  to  it  is  normal;  Imt  here  the  normal  is  so 
easily  disturbed  as  also  to  be  striking.  In  the  animal  that 
spends  much  of  its  life  with  its  nose  pointing  more  or  less  to 
the  earth  these  sinuses  have  a  gravity  drain. 

Third,  the  upper  air  passage  from  biith  to  death  is  sub- 
jected to  recurrent  severe  inflanunatory  attacks  (coryza)  which 
usually  have  no  analogue  or  homologue  in  any  other  part  of  the 
body.  These  attacks  bring  about  changes  in  other  parts  of  the 
upper  air  passage  as  well  as  in  the  nose.  In  the  nose  the  per- 
iosteum is  in  peculiarly  close  relation  to  the  membrane  which 
is  so  frequently  subjected  to  this  inflanniiatory  attack.  In 
most  other  parts  of  the  body  the  periosteum  is  se^Darated  from 

25 


26  HEADACHES    AI^D    EYE    DISORDERS    OF    NASAL    ORIGIN 

its  coverings  by  loose  connective  tissue  which  permits  of  much 
inflammation  of  the  coverings  mthout  involvement  of  it. 

Fourth,  most  of  the  cranial  nerves  leave  the  skull  through 
close  fitting  bony  foramina,  except  those  which  pass  through  the 
sphenoidal  fissure  (the  oculomotor,  trochlear,  abducent,  and  oph- 
thalmic). The  optic,  maxillary  and  Vidian  pass  through  for- 
amina or  canals  in  the  sphenoid  in  a  part  of  the  nose  which  is 
subject  to  the  pernicious  influences  that  beset  the  other  parts 
of  the  nose.  These  nerves  represent  the  special  sense  of  sight, 
as  well  as  the  motor,  sensory  and  sympathetic  systems.  The 
frequency  of  lesions  of  the  optic,  maxillary  and  Vidian  is  at 
once  striking  when  compared  to  the  infrequency  of  the  other 
cranial  nerves.  The  oculomotor,  trochlear,  abducent,  and  oph- 
thalmic in  the  sphenoidal  fissure  are  also  associated  with  a  part 
of  the  sphenoid  which  is  often  a  part  of  the  nose,  but  less  in- 
timately as  a  rule,  for  two  reasons — first,  because  the  sphenoid 
sinus  is  only  sometimes  prolonged  into  the  great  wing  (not  as 
a  rule — if  there  be  anj  rule  for  the  anatomy  of  the  nose)  and 
secondly,  they  are  not  confined  here  in  tight  fitting  bony  fora- 
mina— they  have  loose  connective  tissue  around  them.  The 
sphenoid  sinus  sometimes  extends  to  the  foramen  ovale  and  to 
the  semilunar  ganglion  also,  as  well  as  into  the  great  wing,  but 
only  seldom.  The  nerves  in  the  sphenoidal  fissure  even  though 
they  be  surrounded  by  loose  connective  tissue,  are  more 
often  involved  (from  the  nose)  than  are  the  cranial  nerves 
which  are  totally  removed  from  the  nasal  anatomy.  Further- 
more, these  nerve  complications  are  greatly  increased  by  the 
presence  of  the  nasal  (sphenopalatine — Meckel's)  ganglion,  ly- 
ing almost  submucous  to  the  nose.  It  is,  moreover,  situated  in 
a  fossa  (sphenomaxillary)  Avhich  is  in  many  respects  tanta- 
mount to  a  paranasal  cell.  In  no  other  part  of  the  body  is  a 
sympathetic  ganglion  or  sensory  ganglion  so  exposed  to  sur- 
face influences.  These  facts  bring  these  associated  nerves  with 
all  the  various  questions  arising  with  them,  to  wit,  headaches 
and  eye  disorders,  with  all  that  these  maladies  may  mean  in  the 
life  of  the  patient,  into  the  concern  of  the  rhinologist.  They 
are  also,  of  course,  matters  of  concern  for  the  cranial  surgeon 
Here  the  two  fields  overlap  intimately.  Each,  therefore,  needs 
the  cooperation  of  the  other  to  avoid  errors  in  diagnosis.    These 


THE    NOSE  27 

facts  also  make  the  field  of  the  rhinologist  overlap  that  of  the 
ophthalmologist,  and  here  also  each  needs  the  cooperation  of 
the  other  to  avoid  error.  And  the  same  reasons  make  the  field 
of  the  rhinologist  overlap  that  of  the  internist;  nasal  head- 
aches must  be  differentiated  from  those  of  the  various  systemic 
disorders.  The  neck  and  shoulder  pains  of  some  nasal  diseases 
•call  into  question  the  orthopedic  problems  of  these  parts;  and 
the  dizziness  of  some  nose  disturbances  requires  all  the  cunning 
of  the  internist,  neurologist,  aurist,  and  rhinologist  for  their 
differentiation.  I  have  tried  to  determine  whether  the  hypo- 
physis is  not  sometimes  disturbed  by  inflammation,  but  so  far 
I  have  not  been  able  to  draw  conclusions.  Citelli"^  has  de- 
scribed what  he  believes  are  such  disturbances.  The  paranasal 
cells  are  often  the  source  of  infections  (focal  infections)  which 
supply  organisms  that  are  active  in  other  parts  of  the  body. 
It  is  unfortunate  for  rhinology  that  the  nose  in  animals  is  not 
better  adapted  to  experimentation. 

Headache,  whether  it  be  seldom,  or  frequently  recurrent,  and 
bear  the  names  "Megrim,"  "Bilious-headache,"  "Blind"  or 
"Sick-headache"  or  " Hemicrania, "  like  all  other  pain,  accord- 
ing to  present  thought,  must  be  a  S3Tiiptom  of  a  lesion  of  some 
kind,  whether  a  pathological-histological  change,  or  a  toxemia, 
be  (at  present)  recognized  as  its  cause.  Just  so  it  would  seem 
that  weak  eyes  (asthenopia)  must  be  a  s^anptom  of  a  lesion, 
whether  its  nature  be  kno^ni  noAV  or  not,  and  optic  neuritis  and 
atrophy  and  retinitis  and  choroiditis  must  have  causes  under- 
lying them.  In  these  fields,  as  in  the  domain  of  "hysteria"  and 
"neurasthenia"  and  "syphilis,"  the  number  of  cases  left  in  the 
categories  of  "migraine"  and  "asthenopia"  and  "idiopathic 
optic  neuritis"  and  "idopathic  atrophy"  becomes  smaller  with 
each  advance  in  our  understanding  of  deeper  lying  facts. 

Kecurrent  headache  when  at  all  severe  (or  even  when  slight) 
in  the  course  of  time  becomes  a  matter  of  serious  moment  for  the 
individual ;  and  with  the  higher  grades,  is  the  cause  of  so  much 
disaster  both  in  his  affairs  and  to  the  general  welfare  of  the 
family,  that  from  the  earliest  times  to  the  present  hour  it  has 
had  the  serious  efforts  of  some  of  the  best  minds  bestowed  upon 
the  solution  of  its  causes  and  treatment.     To  this  end,  many 


28  HEADx\CHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

famous  nionograplis  liave  been  written ;  and  special  chapters 
in  all  kinds  of  treatises  and  textbooks,  ^yitlI  eonntless  journal 
articles  have  been  directed  to  tlie  better  understanding  and 
treatment  of  this  symptom. 

Headache  of  any  grade  is  a  symptom  in  many  diseases  that 
are  at  once,  or  easily,  recognizable ;  and  in  the  course  of  which, 
it  needs  no  more  than  the  merest  passing  mention.  These  are 
self-limiting  by  either  recover}^  or  death  in  a  period  of  time 
that  represents  proportionately  a  short  span  in  the  life  of  the 
individual.  But  headache  is  also  a  symptom  of  another  disease 
or  class  of  morl)id  conditions  Avhich  pi'esent  no  signs;  of  which 
it  may  be  the  onUi  siimptom;  and  whicli  are  not  self-l'miit'mo 
by  recovery  or  death  Ijut  persist  throughout  the  life  of  the  in- 
dividual from  childhood  to  age,  and  yet  permit  him  to  live  the 
"allotted  time  of  man."  It  is  this  class  of  headaches  that  in 
earlier  times  were  considered  diseases  per  se.  Hippocrates  did 
not  differentiate  the  headaches.  The  first  to  do  this  was 
Aretaeus  of  Cax^padocia  in  tlie  second  century  A.D.  Galen  in 
that  century,  aside  from  their  description,  advanced  a  theory 
for  their  explanation,  based  on  the  Humoral-pathology  of  Hip- 
pocrates. This  remained  practically  unchanged  until  the  Ee- 
naissance,  since  which  time  many  theories*  have  been  advanced. t 

It  has  lieen  my  opinion  for  hfteen  years  or  more  that  many, 
if  not  all  of  the  diseases  that  produce  this  sym]otom  and  at  the 
same  time  let  the  patient  live  his  life  to  fullness  of  years  and  in 
health  otherwise,  are  some  kind  of  a  disorder  that  involves  the 
nerves  independent  of  the  brain  centres,  that  its  mechanism  is 
a  local  one.  I  have  recently  found  that  this  theory  is  far  from 
original  with  me,  that  it  was  advanced  by  Laborrocpie'^  in  1837 
and  Symonds''^  in  1858.  My  ideas  differ  from  theirs,  however, 
in  some  essentials,  as  will  appear. 

Contributory  to  this  class,  is  the  large  sub-class  of  ocular 
headaches  which  may  endure  as  long  as  the  ocular  defect  re- 
mains unrectified;  and  the  large  sub-class  of  nasal  headaches 
which  may  recur  indetinitely,  made  by  suppurations  of  the  vari- 

*Dubois  Raymond,  Mollendorf,  Laborroque,  Piorry,  etc.  Quoted  by  E.  Liveing:  On 
Megrim,  Sick  Headache,  etc.,  London,  1873. 

tExtensive  historical  references  are  to  be  found  in  many  of  the  monographs  on  Head- 
ache   or   Megrim,    notably    K.    Liveing,    L.    Thomas,    Harry    Campbell,    E.    Flatan,    J.    P.    Moebius. 


0  THE    NOSE  29 

Oils  paranasal  cells.  Botli  of  these  classes  have  been  described 
by  many  of  the  master  jninds  of  our  times  and  much  wondrons, 
admirable  snrg-ical  technic  has  been  evolved  for  their  relief.* 

The  study  of  the  severe  headaches  by  the  authors  of  the 
many  superlative  monographs  has  included  the  local  causes  of 
eye,  ear  and  nose  ever  since  the  understanding  of  these  organs 
began  to  be  comprehensive.  The  eye  through  Helmholtz's  dis- 
covery of  the  ophthalmoscope  was  the  first  to  be  better  under- 
stood. The  ear  also  was  the  object  of  special  study  and  under- 
standing; and  special  study  of  the  anatomy  of  the  nose  and  the 
discovery  of  cocaine  have  done  jnucli  to  ran.k  i-hinology  with 
ophthalmology ;  and  latterly  the  ear  is  nuicli  better  undei'stood. 
Through  the  development  of  these  specialties  the  classes  of 
asthenopia  and  idiopathic  optic  neuritis  and  idiopathic  head- 
aches have  been  much  narrowed. 

It  is  my  desire  here  to  assemble  the  desci'iptions  of  some 
nasal  lesions  which  give  rise  to  these  conditions  without  the 
gross  symptoms  or  signs  that  betray  the  nasal  origin  of  the 
primary  lesion.  The  Avell-knoAvn,  almost  self-evident  paranasal 
sinus  suppurations,  as  well  as  the  many  systemic  and  central 
nerve  causes  for  headaches;  and  the  various  eye  disorders  will 
not  be  considered  here  more  than  to  be  incidentally  mentioned 
when  a  purpose  is  to  be  subserved. 

Perusal  of  the  literature  on  the  subject  of  headaches  re- 
veals that  the  terms  Megrim  (Migrain,  Migraene),  Sick  Head- 
ache, Bilious  Headache,  Blind  Headache,  Hemicrania,  as  used 
by  Liveing,  are  accepted  as  synom  nious  by  most  writers  on  the 
subject.!  Liveing  cites  cases  to  show  that  they  are  complete 
or  incomplete  pictures  of  the  same  disorder.  It  seems  to  me 
that  my  cases  will  also  bear  out  this  argument. 

It  is  the  purpose  of  this  essay  to  describe  three  varieties  of 
nasal  disease  or  clinical  pictures  Avliich  have  as  symptoms,  head- 
ache and  more  or  less  eye  disorder;  to  wit,  (1)  Closure  of  the 
Frontal  Sinus  without  Suppuration,  (2)  The  Syndrome  of  Na- 
sal Ganglion  Neurosis,  (o)  The  Picture  of  Hyperplastic  Sphe- 
noiditis. 


*In  the  list  of  these  procedures  stand  conspicuous  the  Ingals.^=  the  Watson-Williams.'** 
the  Halle, =8  intranasal  frontal,  the  Hajek^*  ethmoidal-sphenoidal,  the  Mosher'"*  fronlal-ethmoidal- 
sphenoidal  (he  Mikulicz-''^  and  the  Denker"  maxillary;  and  the  Killian-'-''  external  frontal  and  the 
■Caldwell'-Luc^''  external   maxillary   operations. 

tE.   Iviveing,^-   Purves   Stewart,'''  Harry   Campbell, ^  J.    P.    iMoebius,"''   Flatau,"  Gowers.- 


CHAPTER  I 

VACUUM  FRONTAL  HEADACHES  WITH  EYE 
SYMPTOMS  ONLY 

A  low  grade  unending  headache  is  established  by  closure 
of  the  frontal  sinus,  without  nasal  symptoms  or  signs,  i.  e.,  ob- 
struction or  secretion,  and  is  made  worse  by  use  of  the  eyes^ 
These  patients  have  ocular  symptoms  only.     The  air  is  partly 


Fig.   7. — Showing   where   needle   has   been    passed   through    the   floor   of   the   frontal    sinus   at    the- 
point   of  attachment    of   the   pulley   of   the   superior   oblique. 

absorbed  in  the  sinus  and  the  negative  pressure  makes  the- 
walls  sensitive.*  The  floor  of  the  sinus  is  its  thinnest  wall  and 
has  attached  to  it  the  pulley  of  the  superior  oblique.  (Figs.  7 
and  8.)  The  sensitive  floor  is  pulled  on  by  use  of  the  ej^es.  I 
once  (1900^^)  thought  that  the  closure  of  the  sinus  was  an  ac- 
cident of  the  anatomy.    I  now  believe  that  this  is  rare  althougk 

*I  have  recently  found  that  this  idea  was  advanced  prior  to  1900  by  P.   McBride*^  in   1891- 

30 


VACUUM    FRONTAL    HEADACHES  31 

possible.  The  mechanism  by  which  closure  is  produced  is  a 
combination  of  unfavorable  anatomical  settings  such  as  narrow 
noses  present,  plus  liyperplastic  changes  in  the  soft  parts  and 
the  hone.     (Compare  Doctor  Wright's  introduction.) 

This  class  of  cases  never  has  pus  in  the  nose;  never  has 
the  severe  pain  produced  by  suppurating  sinuses ;  and  never  is 
complicated  by  blindness  or  changes  within  the  globe.  The  eye 
disturbance  is  of  the  nature  of  "asthenopia."  They  are  almost 
always  closed  frontal  sinuses  which  are  otherwise  normal.  Oc- 
casionally it  is  the  anterior  ethmoidal  lab3^rinth  that  has  become 
closed.    I  have  not  been  able  to  determine  that  contacts  of  one 


Fig.  8. — Showing  a  dissection  of  the  right  orbit  from  above.  /.  Frontal  sinus,  z.  Su- 
perior oblique  muscle,  j.  Pin  passed  from  orbit  into  frontal  sinus  at  point  of  attachment  of 
pulley  of  superior  oblique.     4.   Ethmoidal  cells. 

part  of  the  lateral  wall  with  the  septum  are  ever  responsible  for 
similar  symptoms.  (This  opinion  is  contrary  to  the  statements 
of  some  writers.) 

It  is  my  wish  in  this  chapter  to  classify  from  a  rhinologic 
standpoint,  the  origin  of  this  class  of  cases,  which  was  first  de- 
scribed in  two  papers  presented  by  Dr.  A.  E.  Ewing  and  by 
me  before  the  American  Ophthalmological  Society,  May  2, 
1900." 

Ewing  was  the  first  to  recognize  these  cases  and  to  describe 
the  symptoms,  which  briefly  are :  ' '  Inability  to  use  the  eyes  for 
near  work  because  of  the  headache  which  is  produced  thereby, 


32  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    OKIGIN 

and  wliieh  is  not  relieved  by  glasses  or  eye  treatment."  It  is 
accompanied  liy  a  tender  point  in  the  npper  inner  angle  of  the 
orbit  (Ewing's  Sign). 

This  class  of  cases  is  as  a  rnle  not  accompanied  by  nose 
symptoms,  unless  they  be  prodnced  by  some  lesion  other  than 
the  one  closing  the  sinus.  Occasionally  there  is  some  obstruc- 
tion to  breathing,  l)ecause  of  the  narrow  nose. 

CLINICAL  PICTURE 

The  headache  is  frontal,  usually;  very  rarely  it  is  referred 
to  the  external  angular  process  of  the  frontal  bone.  It  is  fre- 
quently present  on  rising,  but  grows  worse  on  using  the  eyes; 
or  is  brought  on  by  use  of  the  eyes.  The  pain  never  reaches 
the  intense  degree  of  that  produced  by  a  confined  empyema,  but 
is  quite  sufficient  to  prevent  the  use  of  the  eyes.  Occasionally 
a  patient  relates  that  "blowing  his  nose  is  sometimes  accom- 
panied by  a  squeaking  sound  and  sensation  of  air  running  up 
into  his  l)rain,"  which  is  followed  very  soon  by  temporary  re- 
lief of  the  discomfort. 

EWING'S  SIGN 

The  nasal  troul)le  in  these  cases  is  revealed  by  tenderness 
of  the  upper  inner  angle  of  the  orbit  at  the  point  of  attachment 
of  the  pulley  of  the  superior  oblique,  and  internal  and  posterior 
to  it.  (Fig.  9.)  This  is  the  portion  of  the  orbit  which  is  made 
b}^  the  frontal  sinus,  the  wall  of  which  at  this  site  is  thinnest. 
Kuhnt"'  observed  that  in  empyema  of  tlie  frontal  sinus  this  was 
an  exceedingly  sensitive  area,  and  suggested  that  this  tender- 
ness was  in  the  supratrochlear  nerves  which  were  inflamed  be- 
cause of  their  juxtaposition.  As  a  fact,  it  is  in  the  bone  at  a 
point  Avhere  the  nerves  are  absent.*^^  It  should  be  remembered 
that  Ewing'"'  put  forth  this  sign  as  a  diagnostic  help  for  cases 
which  had  up  to  that  time  been  declared  not  frontal  sinus  cases, 
not  nasal  cases  at  all,  because  there  Avere  no  nose  SAonptoms, 
nor  any  pus,  nor  secretion  from  the  sinus,  nor  any  of  the 
grosser  commonplace  anatomic  changes.  This  sign  is  some- 
times the  07ilij  indication  of  the  nasal  trouble,  the  rhinologist's 
findings  being  negative. 


VACUUM    FROKTAL    HEADACHES 


33 


The  frontal  sinus  is  most  frequently  the  one  involved  be- 
cause of  the  peculiar  anatomy  of  its  outlet  (or  inlet).  Rarely 
is  the  anterior  labyrinth  of  the  ethmoid  the  one  involved,  and 
then  the  symptoms  are  different;  and  the  tenderness  is  at  the 
site  of  the  lacrimal  bone.  Patients  affected  this  way  have  the 
feeling  of  sand  in  the  eyes,  and  refer  the  pain  to  ''behind  the 
eyes." 

The  posterior  labyrinth  of  tlie  ethmoid  and  the  sphenoid, 
in  my  oioinion,  never  g'ive  rise  to  these  s^anptoms.  They  may 
give  rise  to  occipital  or  parietal  or  frontal  headache,  or  head- 
ache brought  on  by  use  of  eyes  because  some  of  the  ocular  mus- 


Fig.  9. — Showing  a  needle  ]  as?ed  from  fronfal  sinus  at  a  point  back  of  the  attachment  of 
the  pulley  of  the  superior  oblique.  This  is  the  author's  favorite  point  for  eliciting  "Ewing's 
sign."     Dr.  Ewing  prefers  the  point  of  attachment  of  the  pulley. 

cles  arise  in  the  apex  of  the  orbit  from  i^arts  made  by  the  walls 
of  these  sinuses ;  or  to  blindness  by  reason  of  their  nearness  to 
the  optic  nerve;  but  never  to  this  enduring  low  grade  frontal 
pain  with  inability  to  use  the  eyes,  accompanied  hi/  Eirinrf's 
sign. 

Eighteen  years'  observation  of  this  class  of  cases  leads 
me  to  l)elieve  Ewing's  sign  to  be  trustworthy  and  almost  con- 
stant. The  rare  exception  is  in  the  case  of  the  sinus  having 
very  thick  walls,  when  the  bones  of  the  individual  will  in  geii- 


34  hp:adaches  and  eye  disorders  oe  nasal  origin 

eral  be  found  to  be  very  heavy  and  thick.  Under  these  condi- 
tions I  have  found  it  absent  even  in  acute  empyema  of  the  sinus 
accompanied  by  great  pain. 

GROSS  ETIOLOGY 

In  1900  I"  stated  tliat  I  beheved  the  tenderness  of  the  Avail 
of  the  sinus  arises  secondarily  to  closure  of  its  outlet,  and  that 
a  similar  condition  obtains  here  to  that  produced  in  the  middle 
ear  by  an  acute  closure  of  the  Eustachian  tube.  Many  years 
ago  this  was  recognized  as  a  condition  in  wliich  the  oxygen  of 
the  enclosed  air  was  absorbed  and  a  negative  pressure,  a  par- 
tial vacuum,  estal)lished  within  the  cavity.  Brawle\^^  concurs 
in  this  opinion  of  the  mechanism  of  the  frontal  pain.  I  still 
believe  this  is  the  correct  explanation,  and  that  secondarily  to 
the  closure  of  the  sinus,  arises  a  congestion  of  the  lining  mem- 
brane in  whicli  the  bone  takes  part  to  a  degree  which,  however 
slight,  is  sufficient  to  render  tlie  thin  wall  of  the  sinus  sensitive 
to  external  pressure — even  to  very  sliglit  pressure)  The  pul- 
ley of  the  superior  oblique  is  attached  to  this  thin  wall.  Tlie 
function  of  this  muscle  being  to  turn  the  eye  downward  and 
inward,  it  is  called  into  use  for  most  of  the  acts  of  accommoda- 
tion. So  for  close  work  there  continues,  more  or  less,  a  tug- 
ging at  this  tender  point.  This  intensifies  tlie  dull  ache  made 
by  the  simple  closure  of  the  sinus.  In  cases  of  sliglit  severity 
the  patient  is  not  especially  uncomfortable  until  he  liegins 
using  his  eyes  for  close  work. 

The  frontal  si'^us  is  the  one  by  far  most  frequently  the 
cause  of  this  heada  according  to  my  experience  it  being  the 

origin  of  about  99  "^  fi^-^sA  cases.     The  attempt  to 

classif}^    the  origins  >  esolves  itself,  therefore, 

into  a  reference  to  the  irontv  «  to  that  extent.     For  the 

present  I  shall  neglect  the  other  sinuses.  In  1900  I  made  no 
effort  to  do  more  than  mention  the  ways  in  Avliich  the  outlet 
might  become  closed.  I  did  not  report  cases.  I  felt  that  my 
number  of  cases  was  too  small.  My  material  now  comprises 
580  cases.  These  were  nonsuppurative  at  the  time  they  came 
under  observation;  and  never  at  aii}^  time  showed  pus  in  the 
nose,  nor  did  transillumination  or  x-ray  examination  show  any 
clouding. 


VACUUM    FRONTAL    HEADACHES  35 

ANATOMY  OF  THE  MIDDLE  MEATUS 

Familiarity  with  the  anatomical  detail  of  the  middle 
meatus  is  necessary  for  a  comprehensive  understanding  of  this 
class  of  cases. 

The  Correlated  Anatomy  of  the  Middle  Meatus  of  the  Nose 

These  cases  usuallij  have  narrow  nasal  fossae. 

Closure  of  the  frontal  sinus  outlet  or  inlet  may  be  brought 
about  rather  easily  by  a  number  of  causes,  because  of  its  pecu- 
liar settings.  It  has  ahvays  seemed  to  me  that  a  comprehen- 
sive understanding  of  the  middle  meatus  (which  is  the  begin- 
ning of  the  inlet)  would  have  to  come  through  a  correlative 
study  of  the  district.  In  this  Avay  only,  can  an  understanding 
of  the  workings  of  this  region  be  had.  These  anatomical  ob- 
servations relate  to  tlie  anterior  ethmoid  cells  also. 

The  extant  anatomical  descriptions  of  the  parts  of  the 
middle  meatus  and  its  paranasal  cells  and  their  means  of  com- 
munication with  it,  as  Avell  as  the  terms  employed,  are  so  various 
that  an  effort  to  synonymize  them  would  be  difficult  if  indeed 
possible.  This  arises  probably  from  the  fact  that  the  various 
observers  have  each  seen  the  parts  variously,  together  with 
the  difficulty  anatomists  have  (apparently)  had  in  understand- 
ing each  others'  description.  Heymann  and  Kitter"°  in  a  mas- 
terful presentation  of  the  entire  set  of  cpiestions,  with  the 
confusions,  besetting  this  district  have  systematized  them  for 
a  comprehensive  understanding  and  catalogued  their  varia- 
tions. The  term  Infundibulum  was  i^  luced  by  Boyer*  in 
1803  to  designate  the  flat^^^nesl  f  ped  uppermost  part 

of  the  middle  meatus  le^,  ntal  sinus,  which  in  its 

simplest  arrangement  p^  -^t-.y     between    the    uncinate 

process  in  front  and  ethmoidal  bulla  behind,  i.  e.,  smoothly,  di- 
rectly upward  from  the  hiatus  semilunaris,  uncomplicated  by 
pocketings,  cells,  or  diverticula  in  any  direction.  (Boyer  in- 
terpreted the  infundibulum  as  an  ethmoid  cell.)  This  then 
means  that  as  long  as  the  neck  of  funnel  runs  in  parallel  lines 
it  is  the  hiatus  semilunaris  and  as  soon  as  its  lines  diverge  it 
becomes  the  infundibulum.  This  is  the  construction  and  ac- 
ceptation that  the  B.  N.  A.  puts  upon  this  district.    These  Avere 


36 


HEADACHES    AND    EYE    DISORDERS    OF    ISTASAL    ORIGIN" 


also  the  ideas  of  Zuckerkandl/"'  Logan  Turner,''-  Milialcovics,^^ 
This  complete  fiattened-funnel  (cone  and  neck)  is  smooth  lined. 
But  this  smooth-lined  funnel  is  varied  in  many  ways  by  pocket- 
ings  or  cells  developing  anteriorly,  laterally,  superior!}^  and 
posteriorly  from  both  infundi])ulum  and  hiatus;  and  by  the 
hiatus  becoming  disjointed  as  it  were  from  the  infundibulum. 
These  variations  Avere  also  ol)served  by  Boyer.  lleymann  and 
Ritter  have  apparently  fallen  the  view  that  the  simple  smooth- 


Fig.  10. — Showing  hiatus  semilunaris,  in 
fundibulum  and  frontal  sinus  in  direct  and 
uncomplicated  connection.  •/.  Frontal  sinus. 
2.  Infundibulum.  .?.  Line  of  attachment  of 
■middle  turbinate.  4.  Hiatus  semilunaris.  3. 
Norma!    outlet    of    anterior   ethmoid    cells. 


Fig.  12. — Showing  ethmoid  cells  entering  in- 
fundibulum and  hiatus  semilunaris  from  above 
and    below    in    front.      /.    Ethmoid    cells. 


Fie.  U. — Showing  ethmoid  cell  entering  in- 
fundibulum from  above  and  behind.  /.  Eth- 
moid   cell. 


Fig.  13. — Showing  ethmoid  cell,s  entering  in- 
fundil)ulum  and  hiatus  semilunaris  from  above 
in  front  and  behind  and  below.  1-2-3.  In- 
fundibulum  and   hiatus   cells. 


lined  funnel  does  not  exist  and  have  started  with  the  next  sim- 
ple arrangement,  that  of  the  cone  and  neck  (infundibulum  and 
hiatus)  being  slightly  disjointed.  They  have  then  shown  all 
the  variations  in  logical  sequence,  so  clear  is  their  systematiz- 
ing of  the  district.  Figs.  10  to  17  show  diagrammatically  the 
commonplace  variations  in  the  scheme  of  these  parts.  Fig.  18 
shows  a  specimen  in  which  there  is  no  expanse  of  the  breadth 
of  the  hiatus  semilunaris  at  any  point.    It  communicates  with 


VACUUM    FEOXTAL    HEADACHES 


37 


frontal  sinus  In'  a  pipe-like  channel  wliieli  has  become  more 
nearly  horizontal,  but  not  any  wider.  A  large  ethmoid  cell 
enters  this  channel  from  behnx-  and  in  front. 

As  a  rule  anatomists  have  described  the  Avay  the  frontal 
sinus  communicates  with  the  middle  meatus.  For  my  purpose 
it  is'  advantageous  to  emphasize  the  way  the  middle  meatus 
oommunicates  with  the  frontal  siiras. 

The  means  of  connnunication  of  the  middle  meatus  with 


Fig.  14. — Showing  hiatus  semilunaris  end- 
ing in  blind  pocket  above,  infundibulum  limited 
above  by  roof  of  nose.  Frontal  sinus  enter- 
ing infundibulum  from  above  and  laterally. 
/.  Frontal  sinus.  .'.  Outlet  of  frontal  sinus. 
S.   Infundibulum. 


Fig.  16. — Showing  (/  and  i)  ethmoid  cells 
opening  into  h-atus  semilunaris  which  ends 
above  in  a  blind  pocket.  The  frontal  sinus 
enters  the  nose  at  a  point  above  and  behind 
the  hiatus  semilunaris  as  shown  by  bristle  in 
position. 


Fig.  15. — /.  Frontal  sinus.  .'.  Bristle  passed 
from  frontal  sinus  into  hiatus  semilunaris. 
( Note  that  it  takes  a  much  more  horizontal 
direction  than  usual.)  5.  A  large  hiatus  cell  of 
tlie   ethmoid. 


Fig.  17. — Showing  hiatus  semilunaris  end- 
ing in  blind  pocket  above.  ;.  Hiatus  semi- 
lunaris. ..'-.^-V-  Ethmoid  cells  entering  infundi 
bulum  from  above,  in  front  and  behind,  and 
from  above  and  laterally  in  common  with 
lower    ethmoid    cell    4. 


the  frontal  sinus  are  primarily  from  the  'S'ault"  of  the  mid- 
dle meatus  through  or  by  Avay  of  its  '' frontal  pouch."  AA'liat- 
ever  may  be  the  further  (upper)  subdivision  of  the  passway, 
i.  e.,  hiatus  semilunaris,  infundibulum,  nasofrontal  duct,  the 
start  from  below  is,  under  the  middle  turbinate  into  the  ' ''  vault ' ' 
which  is  pouched  upward  at  a  point  in  the  anterior  third. 

"Vault"  is  a  term  that  I  employ  to  designate  the  entire 
uppermost  extent  of  tlie  middle  meatus.  At  the  junction  of  the 
anterior  with  the  middle  tliird  of  this  space  it  extends  upward, 


do  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

pocket-like,  to  eventually  coinmiinicate  with  the  frontal  sinus. 
This  particular  district  it  seems  to  me  may  be  advantageously 
termed  the  frontal  iioiicli  of  the  vault  of  the  middle  meatus. 
This  pouch  has  been  observed  and  named  by  Killian^*  "recessus 
frontalis,"  and  by  Mihalkovics^'  ''recessus  meatus  medii" 
(Tasche  des  mittleren  Nasenganges).  Its  association  with  the 
remaining  vault  has  not  been  described.  At  about  the  middle 
of  the  vault,  behind  and  above  the  l)ulla,  is  a  similar  smaller 
pouch  which  communicates  with  the  anterior  ethmoidal  outlet 
or  inlet,  which  may  be  termed  the  ethmoidal  pouch  of  the  vault 


Fig.  18. — The  hiatus  semilunaris  in  this  specimen  does  not  expand  as  it  passes  upward. 
It  is  situated  unusually  far  back  and  communicates  with  the  frontal  sinus  by  a  channel  more 
horizontal  than  usual. 


of  the  middle  meatus.  The  frontal  pouch  is  usually  not  only 
larger  but  extends  higher  than  the  ethmoidal  pouch.  For  the 
maintenance  of  these  pouches  and  their  communication  mth 
the  middle  meatus,  it  is  necessary  that  the  middle  turbinate 
occupy  a  position  somewhat  raised  from  the  lateral  walk  Any- 
thing which  i^resses  the  turbinate  outward  closes  these  pouches ; 
or  they  may  be  closed  by  swelling  of  the  membrane  in  the  vault 
even  though  the  turbinate  be  in  normal  position  and  otherwise 
normal;  for  these  spaces  at  most  are  small.     Examination  of 


VACUUM    FROXTAL    HEADACHES 


39 


the  distrilnitioii  of  the  cavernous  tissue  of  the  anterior  half  of 
the  middle  tiirl^inate  shows  that  it  often  extends  upward  on  the 
lateral  surface  of  the  turbinate  into  the  frontal  pouch  of  the 
vault  (Fig.  19).  Fig.  20  shows  what  appears  to  be  normal  con- 
ditions.    The  rule,  hoAvever,  is  that  it  should  not  extend  so  far 


yp  .2 


Fig.  19. — Three-quarter  view  of  lateral  wall  from  below  uinvard  and  outward.  Shows 
/-»  line  of  amputation  of  middle  turbinate  with  the  line  of  origin  from  the  lateral  wall.  3. 
Cavernous  tissue  on  the  internal  aspect  of  frontal  pouch. 

up.    Fig  21  shows  a  striking  absence  of  cavernous  tissue  in  this 
district  of  an  otherwise  normal  nose. 

The  lateral  wall  of  the  pouch  is  marked  lielow  by  the  begin- 
ning of  the  hiatus  semilunaris  bounded  In'  the  uncinate  process  in 
front  and  the  bulla  ethmoidalis  Ijehind.    It  mav  have  lateral  and 


40 


HEADACHES   AN^D    EYE    DISORDERS    OF    NASAL    ORIGIlSr 


antero-posterior  measurements  of  as  much  as  3  nmi.  each.    The 
uncinate  and  bulla  ma}^  be  on  the  same  plane  which,  however,  is 


Fig.  20. — Three-quarter  view  of  a  normal  left  lateral  wall  from  below  upward  and 
outward.  /.  Orbit.  2.  Middle  turbinate.  i.  Sphenoid  sinus.  4.  Eustachian  tube  orifice.  5. 
Soft  palate.     Compare  Fig.   19. 

not  the  rule.  The  bulla  is  usually  well  internal  to  the  plane  of 
the  uncinate  and  often  fitted  accurately  into  a  corresponding- 
cup  on  the  lateral  aspect  of  the  middle  turbinate.     (Fig.  22.) 


VACUUM    FROXTAL    HEADACHES 


41 


The  bulla  may  have  come  forward  to  meet  the  loAver  part  of  the 
uncinate  and  obliterate  the  Jovrest  part  of  the  hiatus  or  it  may 
extend  this  contact  higher  up  (Fig.  23).  Under  these  condi- 
tions the  inlet  of  the  frontal  sinus  is  closed  in  the  middle  meatus 
unless  the  pouch  in  its  internal  limitation  be  of  sufficient  am- 
plitude to  permit  it  to  extend  both  al)ove  and  internal  to  the 
bulla.  Under  such  conditions  (closure  of  hiatus)  sJioidd  the 
cavernous  tissue  extend  into  the  pouch  it  will,  upon  slight  sivell- 


Fig.  21. — Three-quarter  view  of  lateral  wall  seen  from  below  upward  and  outward. 
1-2.  Free  margin  of  middle  turbinate  showing  total  absence  of  cavernous  tissue.  This  specimen 
is    otherwise   apparently    normal."    5.   Uncinate   process. 

ing,  close  it  as  a  cork  stops  a  bottle  (see  Fig.  19).  The  main 
mass  of  tlie  cavernous  tissue  of  the  middle  turbinate  is  devel- 
oped on  its  lower  half.  Frequently,  the  bulla  behind  and  the 
lower  limit  of  the  uncinate  in  front  occupy  a  position  just  above 
this  line  and  project  inward  beyond  the  plane  of  the  lower  part 
of  the  lateral  wall  of  the  middle  meatus  mth  a  shelf -like  resem- 
blance under  which  rests  the  extei-nal  half  of  the  mass  of  the 
cavernous  tissue.     These  conditions  are  nearlv  ahvavs  found 


42 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


when  the  markings  on  the  lateral  -^vall  are,  in  general,  empha- 
sized (Fig.  23).  Tlie  nose  that  shows  snch  markings  is  apt  to 
have  the  tubercle  of  the  septum  also  well  marked  (Fig.  24), 
and  to  be  of  scant  space  because  of  the  full  development  of  all 


P"ig.  22. — Lateral  view  showing  middle  turbinate  detached  in  its  anterior  two-thirds  and 
turned  up  at  /.  Bulla  ethmoidalis.  2.  Cup  on  lateral  surface  of  turbinate  into  which  bulla  was 
accurately  fitted  as  shown   in  three-quarter  view   in   Fig.    15. 

Fig.  23. — Three-quarter  view  from  below  upward  and  outward.  This  anterior  middle 
meatus  was  closed.  Showing  bulla  ethmoidalis  /  in  contact  with  processus  vincinat'us.  2.  This 
contact  extends  far  above  line  of  attachment  of  middle  turbinate  to  lateral  wall  jj.  4.  Cup  on 
lateral  wall   into  which   middle  turliinate   was   fitted. 


the  tissues  within  the  (usually)  narrow  nasal  fossa.  The  great- 
est development  of  cavernous  tissue  on  the  middle  turbinate  is 
over  its  anterior  third.     Just  below,  in  front  and  internal  to 


VACUUM    FROXTAL    HEADACHES 


43 


this  mass  of  cavernous  tissue  is  developed  the  tubercle  of  the 
septum.  In  many  specimens  the  relations  of  the  middle  tur- 
binate are  so  intimate  (close)  that  the  outline  of  its  anterior 
third  or  half  is  clearly  graven  not  only  upon  the  tubercle  below 
and  in  front  (Fig.  25)  but  equally  upon  the  lateral  wall  (Fig. 
23).    The  depression  on  tlie  lateral  wall  combined  with  that  on 


Fig.  24. — Septum  of  specimen  shown  in  Fig.  23.  Showing  well-marked  tubercle  /and 
deeply  marked  imprint  of  entire  middle  turbinate  z.  This  septum  was  not  deflected  to  either 
side. 


the  tubercle  then  forms  more  or  less  completely  a  rigid  case 
in  Avhich  the  turbinate  is  enclosed.  In  normal  noses  these  mark- 
ings are  poorly  defined  or  absent:  and  the  turbinate  has  room 
to  hang  free  in  its  confines— that  is,  there  is  room  between  it 
and  the  septum  and  between  it  and  tlie  lateral  wall  (Fig  26). 


44 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


These  spaces  may  be  slightly  narrowed.  Then  there  will  be 
only  moderate  marking  of  the  turbinate  on  both  walls.  Should 
these  spaces  be  wide,  that  is,  wide  enough  to  allow  normal  ex- 
cursions of  the  cavernous  tissue  without  its  being  clamped, 
neither  the  lateral  wall  nor  the  septum  will  be  marked  (Fig. 


Fig.  25. — Sagittal  section  through  the  capsule  of  the  ethmoid  left  side  showing  relations. 
of  middle  turbinate  (attached)  to  the  tubercle  of  the  septum  /.  i.  Middle  turbinate  sharply- 
graven  into  the  septum  in  its  entire  length.  The  tubercle  of  this  septum  is  very  well  marked 
but  not  deflected. 


26).    In  some  narrow  noses  the  imprint  of  the  turlrinate  on  both, 
walls  is  perfect  throughout  its  length  (Figs.  23  and  25). 

A  tilting  of  the  septum  to  one  side,  even  though  slight,  is 
very  apt  by  the  help  of  the  tubercle  to  close  the  lower  slit  open- 
ing of  these  case-like  confines.  A  clamping  of  the  turbinate 
below  by  a  septal  spur  (Figs.  27,  28  and  29)  or  ridge  is  equally 


A^ACUITM    FROXTAL    HEADACHES 


45 


or  even  more  eflieacious.  Swelling  of  the  cavernons  tissue  then 
can  take  only  an  upward  dirc^ction  into  the  olfactory  fissure 
and  the  vault  of  the  middle  meatus. 

In  that  way  the  lowest  part  or  heginning  of  the  frontal 
inlet  may  be  closed.  The  uncinate  and  the  hulla  with  the  hiatus 
between  them  are  present  on  the  lateral  wall  at  this  (lower) 
level  and  extend  thence  upward  and  foi-ward.     Xormallv  the 


'1      \ 

A      j«_  V 

vW          ^ 

JH^    ^ 

•W   ' 

\ 

■'  '> 

■\  / 

\ 

Fig.   26. — Showing  middle   turbinate   /   placed   with    free   si?ace   between   septum    and    lateral    wall. 

hiatus  should  remain  open  from  below  upward  into  the  infun- 
dibulum.  The  bulla,  however,  is  often  developed  from  behind 
and  below  in  a  forward  and  upward,  or  upward  and  forward 
direction  to  meet  the  uncinate  process,  and  for  a  longer  or 
shorter  distance,  obliterates  the  hiatus  (Fig.  23).  This  is  usu- 
ally on  the  line  of  origin  of  the  ])endulous  or  free  middle  tur- 
binate  from  the   lateral  wall,  Avhich  line  may   be   accurately 


46 


HEADACHES   AXD    EYE    DISORDERS    OF    jSTASAL    ORIGIN 


located  at  the  anterior  limit  of  the  origin  of  the  turbinate.  The 
frontal  pouch  is  not  necessarily  closed,  however,  by  the  oblit- 
eration of  the  liiatus,  as  it  should  still  have  an  opening  internal 
to  the  plane  of  this  closure  and  may  have  its  uppermost  dimen- 
sions undisturbed  by  it.  But  should  the  huRa  develop  further 
in  the  directions  of  upward  and  forward,  it  will  be  found  to 
develop  also  inirard  and  hackivard  to  fit  tight  under  the  tur- 
binate, and  so  close  the  frontal  and  ethmoidal  pouches  from  all 


Fig.  27. — Showing  septum   tiiljercle  well  marked  almost  like   spur  at  the  site  of  its  tubercle.     R  I 
shows  a  mechanical  drawing  of  same  seen  from  in  R   ii  front. 


directions  and  completely  (Figs.  22  and  23).  This  may  often  be 
discovered  by  the  use  of  Killian's  long  speculum  inserted  be- 
tween the  middle  turbinate  and  the  lateral  wall  (Killian's  rhi- 
noscopic  media). 

Above  the  limit  of  the  frontal  pouch  is  the  infundibulum, 
whicli  is  usually  more  capacious  and  is  not  so  readily  closed  in 
the  manner  just  described.  The  opening  of  the  infundibulum 
into  the  frontal  sinus,  however,  may  be  small  and  tortuous  as 
pictured  (Fig.  18). 


VACUUM    FEOXTAL    HEADACHES 


47 


Patholog-y  and  Method  of  Closure. — The  nietliod  of  closure 
(or  accidents  of  the  anatomy)  of  these  vacuum  iiasal  headaches 
may  he  divided  into  six  classes.  The  histological  changes  re- 
corded in  these  classifications  are  the  observations  of  Dr.  Jona- 
than Wright  from  207  specimens. 

Class  I. — From  tlie  alcove  correlation  of  the  parts  of  the 
middle  meatus  it  may  readily  l)e  seen  that  enlargement  of  the 


Fig.    28. — Showing-    posterior    spur    /    and    well-marked    ridge    S-4    with    large    tubercle.      .».    This 
septum   would  clamp   the   middle  turbinate   in   front,   below  and  behind. 


septum  tubercle  or  the  tilting  of  it  out  of  the  middle  line  in  a 
normal  or  particidarli)  in  a  narroiv-  nose  will  so  narrow  the 
confines  of  the  middle  turbinate  as  to  cause  the  cavernous  s^vell- 
ing  to  take  the  direction  of  the  vault  and  its  pouches,  and  in 
this  way  close  the  inlet  of  the  frontal  sinus  at  its  ])eginning. 
In  a  stud}^  of  451  vacuum  frontal  cases,"''  38%  proved  to  have 


48 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN" 


been  establislied  in.  this  way,  i.  e.,  to  have  this  mechanism  as 
an  etiology.  The  tnrbinate  is  liistologically  normal.  The  eti- 
ology of  the  deflected  septnm  then  comes  into  causal  relation 
(see  Mosher^**  and  liack^^). 

Class  II. — Noses  with  clinical  appearances  normal.  By 
"this  I  mean  that  the  middle  tnrl)inate  is  not  hypertrophied ; 
that  the  tubercle  of  the  septum  is  normal;  that  the  vault  of  the 
middle  meatus  is  open.  In  this  class  of  cases  there  is  no  history 
-of  empyema  or  of  coryza  as  starting  the  trouble.     Tliese  Avere 


5>\t.vvt^ 


Tig.   29. — Cross    section    in    posterior    part    of    nose    showing    spurs    2-4    above    and    below    middle 
turbinate  .5.     /.   Upper  turbinate. 

the  most  mysterious  until  they  were  operated  upon;  that  is, 
the  middle  turbinate  removed.  Then  it  was  found  that  the 
hiatus  semilunaris  was  narrowed  or  occluded,  by  bony  narrow- 
ing, the  uncinate  process  and  bulla  being  in  contact.  It  Avas 
this  class  of  cases  that  I  emphasized  in  the  title  of  my  paper  in 
1900.""  xVt  that  time  I  thought  them  to  be  more  frequent  than 
subsecpient  experience  has  proved  them.  (The  tubercle  class  I 
find  is  larger.)  Twenty-four  per  cent  of  the  cases  were  of  this 
origin.    The  turbinates  showed  thickened  periosteum  mtli  great 


VACUUM    FROXTAL    HEADACHES  49 

bone  activity,  active  osteoblasts  and  few  osteoclasts  with  large 
}3one  areas. 

Class  III. — Edema  of  the  vault  of  middle  meatus.  The 
vault  of  the  middle  meatus  may  be  closed  by  swelling  of  its 
soft  tissues  (edema)  without  special  hypertrophy  of  the  soft 
tissues  of  the  middle  turbinate  proper,  that  is,  of  the  cavernous 
portion  of  the  middle  turbinate.  Under  the  influence  of  an 
acute  coryza  these  noses  often  develop  polyps.  As  the  coryza 
subsides  the  polyps  subside,  but  the  edema  remains.  Fifteen 
per  cent  of  the  cases  were  of  this  origin.  The  turbinates  showed 
some  connective  tissue  in  the  stroma  of  the  mucosa  without 
any  great  activity  in  the  bone,  nor  was  the  amount  of  bone  in- 
<3reased.    Some  new  bone  formation  showed  at  some  places. 

In  these  patients,  in  whom  the  middle  turl)inate  has  been 
removed,  I  have  niaii}^  times  seen,  during  a  coi-yza,  the  hiatus 
semilunaris  All  out  with  an  edema  and  develop  broad-base 
potyps  in  the  hiatus  and  over  the  bulla,  accompanied  (without 
pus)  by  all  the  symptoms  and  signs  of  the  original  case.  These 
would  subside  in  a  little  longer  time  than  is  required  for  a 
coryza  in  a  normal  nose  and  would  not  appear  again  until  the 
uext  coryza.  As  tiine  goes  on,  however,  the  condition  gets  more 
marked  until  the  polyps  are  permanent. 

Class  IV. — Middle  turbinate  hypertrophy.  The  vault  of 
the  middle  meatus  may  l^e  closed  by  hypertrophy  of  the  mid- 
dle turbinate,  uncomplicated  l)y  suppuration  or  polyps.  Eleven 
per  cent  of  the  cases  were  of  this  origin.  Turlnnates  from  this 
•class  showed  the  same  changes  as  Classes  IT,  III  and  VI,  but 
more  marked. 

Class  V. — Anatomical  insufficiency  of  vault.  The  vault 
of  the  middle  meatus  may  be  obliterated  by  the  middle  turbin- 
ate being  simply  lapped  down  against  the  external  wall,  in  a 
nose  that  is  otherwise  normal.  Seven  per  cent  of  the  cases 
were  of  this  origin.  This  seems  an  anatomical  ])eculiarity;  al- 
though the  more  I  observe  the  nose,  the  more  it  seems  to  me 
that  it  is  the  result  of  a  correlated  influence  in  the  past  that 
has  left  no  trace  in  its  wake.  Turl)inates  of  tliis  class  were 
normal. 

Class  VI. — Empyemas  or  coryzas  without  suppuration 
which  have  got  well,  l)ut  have  left  a  degree  of  swelling  in  the 


50  HEADACHES    AND    EYE    DISORDEES    OF    NASAL    ORIGIN 

vault  of  the  middle  meatus  siiffieient  to  keep  the  frontal  sinus 
closed  and  so  keep  up  enough  pain  to  render  the  eyes  unfit  for 
ordinary  work.  Three  ]3er  cent  of  the  cases  were  of  this  origin. 
(These  cases  might  be  said  to  beloiig  to  Class  III.  They  are, 
however,  in  a  different  stage  of  development.) 

In  addition  to  these  chronic  cases,  one  occasionally  sees 
others  that  are  excited  by  an  acute  coryza  (without  sinus  sup- 
puration) by  reason  of  the  sw^elling  of  the  memljrane  in  gen- 
eral, and  sul3side  with  tlie  coryza,  spontaneously.  I  have  con- 
strued tliese  cases  as  having  a  small  inlet  to  the  frontal  sinus. 
Swelling  of  the  ineml)rane  in  the  vault  from  the  coryza  is  suf- 
ficient to  close  the  inlet,  but  as  soon  as  the  coiyza  subsides, 
the  swelling  also  subsides ;  and  tlie  sinus  opens ;  and  the  symp- 
toms subside. 

Ehinologists  at  the  present  time  usually  demand  the  pres- 
ence of  pus  coining  from  the  paranasal  cells  as  essential  for  the 
clinical  diagnosis  of  the  painful  diseases  of  these  cells,  and 
many  superlative  treatises  upon  these  forms  of  their  diseases 
have  appeared  in  the  recent  past  at  the  hands  of  the  modern 
masters.  Clinical  recognition  of  changes  in  the  ethmoid  bone 
consequent  to  or  upon  inflammation  of  the  mucous  membrane 
was  begun  with  the  observations  of  Edw.  Woakes"'  in  1885  and 
have  finally  been  concluded  in  the  chapter  of  Hyperplastic  Eth- 
moiditis  by  E.  Zuckerkandl,'''  L.  Gruenwald,-^  M.  Hajek,-^  H. 
Cordes,^-  W.  Ulfenorde,-'^''  and  Cholewa."  These  observations 
relate  to  the  anterior  ethmoid  only.  Doctor  AVright's  obser- 
vations summarized  in  the  introduction  form  an  additional  and 
conclusive  chapter  on  this  sul3Ject. 

Woakes  was  a  shrewd  enough  ol)server  clinically  to  recog- 
nize that  polyps  were  secondary  to  other  changes  in  the  nose. 
This  was  a  great  advance.  His  method  of  investigation,  how- 
ever, was  unfortunate,  seemingly.  He  used  and  recommended 
a  small  pointed  probe,  a  "canniliculus  probe,"  stating  that  the 
bulb-tipped  probes  did  not  answer  the  purpose.  (It  would  seem 
that  for  the  purpose  of  jjalpation  the  Imlbous-tipped  probe 
would  give  much  more  trustworthy  results.)  And  he  adhered 
to  an  unfortunate  name,  "necrosing  ethmoiditis,"  even  after 
Dr.  Sidney  Martin^"  who  made  tlie  microscopical  pathological 
examinations  for  him  had  disclaimed  that  "necrosis"  could  be 


VACUUM  fro:n^tal  headaches 


51 


recognized.  A  perusal  of  his  (Woakes)  text,  in  the  light  of  the 
present,  gives  the  impression  that  he  observed  several  classes 
of  cases  with  the  common  factor,  rarefying  osteitis  (which  may 
have  given  the  impression  of  necrosis  on  palpation).  Undoubt- 
edly he  observed  hyperplastic  ethmoiditis  without  pus  and  with 
pus.  Hajek-^  gave  the  first  full  account  of  the  microscopic 
changes  in  the  process  underlying  polyp  formations  and  proved 


Fig.  30. — Wood's  metal  casts  of  a  narrow  middle  meatus,  i.  Projection  leading  into  a 
narrow,  small  frontal  pouch,  representing  a  small  infundibnlum.  .'.  Small  iirojection  representing 
a  small  ethmoidal  pouch.  5.  Mass  of  metal  which  had  flowrii  into  maxillary  sinus  (through  a 
large  opening).  4.  A  small  groove  made  by  a  poorly  marked  uncinate  iirocess.  In  this  specimen 
the  middle  turbinate  laid  close  to  the  lateral  wall.  A  shows  front  view  of  cast;  B  shows  in- 
ternal surface;    C  shows   external   surface. 


Fig.  31. — Wood's  metal  casts  of  a  wide  middle  meatus.  i.  Projection  representing 
frontal  pouch.  2.  Small  projection  representing  ethmoidal  pouch.  3.  Projection  marking  the 
entrance  into  maxillary  sinus.  4.  Groove  made  by  uncinate  process.  5.  Ridge  made  by  hiatus 
semilunaris.  6.  Groove  made  by  ridge  on  external  surface  of  turbinate.  7-  Excess  of  metal. 
A,  front  view;   B,  internal   surface;    C,   external  surface. 

Observe  that  although  this  meatus  was  wide  in  its  lower  part,  the  entire  vault  was 
quite   narrow.      The   frontal   and    ethmoidal   pouches   are   rapidly   obliterated    from   below    upward. 

it  to  be  "hyperplastic  ethmoiditis."  Cordes''  and  Uffenorde^^ 
corroborated  his  findings,  the  latter  giving  a  detailed  descrip- 
tion in  his  monograph  of  the  clinical  as  well  as  the  pathological 
aspects  of  the  problem.     Cholewa'^  contested  llajek's  findings. 


52 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


At  tlie  time  of  the  controversy  over  AVoakes'  statements  a 
most  interesting  discussion  on  the  '* Etiology  of  Mucous  Polypi 
of  the  Nose"  was  held  in  the  Section  of  Ijaryngology  and  Rhi- 
nology  of  the  British  Medical  Assn.,  1895,  (British  Med.  Jour., 
Aug.  24,  1895.)  Many  of  the  most  prominent  rhinologists  of 
the  day  took  part  in  it ;  to  wit,  Uuye,  Luc,  Zuckerkandl,  McBride, 
Hodgkinson,  Spieer,  Hill,  Bcsworth,  Schmidt,  Daly,  Mackenzie, 
Newman,  Lake,  AYilliams  and  de  Eoaldes.     Many  ideas  were 


2- 


Fig.  il. — Wood's  metal  case  of  a  wide  middle  meatus  with  wide  frontal  and  ethmoidal 
pouches  readily  permitting  the  flow  of  metal  into  frontal  and  ethmoidal  sinuses.  A,  front 
view;  B.  internal  view;  C.  external  view.  /.  Frontal  jiouch.  .'.  Ethmoidal  pouch.  5.  Cast 
of    opening    into    maxillary    sinus. 


Fig.  ii. — Wood's  metal  cast  of  very  wide  middle  meatus  with  very  wide  frontal  and 
ethmoidal  pouches  readily  permitting  flow  of  metal  into  frontal  ethmoidal  cells.  /.  Cast  of 
part  of -very  large  frontal  sinus.  2.  Cast  of  an  ethmoidal  cell.  ;?.  Very  large  hiatus  semilunaris 
and  infundibulum. 

expressed  more  or  less  approaching  the  present  day  views. 
Conspicuous  are  those  of  Zuckerkandl  and  P.  Watson-AVilliams. 
The  former  stated  that  instead  of  a  necrosing  process  at  the 
base  of  the  polyp  he  found  an  hypertrophic  process  in  the  bone 
as  well  as  in  the  soft  parts  but  no  necrosis.  Dr.  Williams  stated 
that  he  has  observed  ''formative  and  rarefying  osteitis  in  the 
base  of  polyps."     These  are  Hajek's  findings  which  are  given 


VACUUM    FEO]S^TAL    HEADACHES  53 

in  full  detail.  Hajek  stated  Martin's  findings  in  their  essentials 
correspond  with  his. 

The  anatomy  of  the  nose  was  first  described  in  detail  by 
Zuckerkandl,  otherwise  anatomists  have  given  only  descriptions 
of  the  more  self-evident.  Since  the  time  of  Znckerkandl  rhi- 
nologists  have  added  nmch  detailed  observation. 

The  methods  of  closure  of  the  frontal  simis  from  the  above 
description  may  appear  to  l)e  accidents  of  the  anatomy,  and 
such  was  my  idea  for  a  number  of  years.  Continued  ol)serva- 
tion  of  these  cases,  however,  has  led  me  to  believe  that  ana- 
tomical accidents  may  be  unfavorable  to  the  communication  of 
the  sinus  with  the  nose  and  that  these  are  more  marked  in  a 
narrow  nose  than  a  wide  one,  as  shown  l)y  the  casts  of  such 
noses  (Figs.  30  and  33),  1)ut  that  the  real,  underlying  trouble  is 
usually  not  a  pure  anatomical  accident.  It  is  usually  thicken- 
ing process  in  the  membrane  and  bone  sunnned  up  under  the 
caption  ''hyperplastic  process"  and  further  designated  by  the 
locality  in  which  it  is  found.  The  present  descriptions  of  this 
lesion  limit  it  to  the  anterior  ethmoid  "hyperplastic  ethmoid- 
itis,"  l)ut  according  to  my  observation  it  may  begin  and  remain 
in  other  parts  also,  Avitli  more  or  less  pernicious  effects,  accord- 
ing to  the  parts  involved. 

DIFFERENTIAL  DIAGNOSIS 

The  supraorbital  nerve  emerges  from  the  orbit  at  the  junc- 
tion of  the  inner  and  the  middle  thirds  of  the  supraorbital  ridge. 
At  this  point  it  passes  through  the  supraorbital  notch,  and  is 
distinctly  accessible  to  finger  pressure.  Under  normal  condi- 
tions the  site  of  this  nerve  is  the  most  sensitive  part  of  this 
area.  The  pressure  tolerated  by  it  normally  is  little.  Tn  neu- 
ralgia of  the  supraorbital  it  becomes  very  nmch  less.  The 
pressure  tolerated  by  that  portion  of  the  orbit  Avhich  lies  inter- 
nal and  posterior  to  the  supraorbital  notch,  which  is  made  by 
tiie  thinnest  wall  of  the  frontal  sinus,  is  normally  much  greater 
than  the  nerve  will  tolerate.  AVlien  the  nerve  is  innniaJ  and 
the  frontal  sinus  closed,  the  orbit  interiortij  and  posteriori ij  to 
the  supraorbital  notch  becomes  as  sensitive  or  more  sensitive 
than  the  nerve  it-^^df.    The  supratrochlear  as  well  as  tlie  supra- 


54  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

orbital  nerves  are  external  to  Ewing's  tender  spot.    The  supra- 
orbital is  more  accessible  for  tests. 

Headaches  from  all  Causes  and  Their  Separation  from  That 

Produced  by  Closure  of  the  Frontal  Sinus 

Without  Suppuration 

Closure  of  the  frontal  sinus  gives  Ewing's  sign  (see  above). 
This  is  not  found  in  headaches  produced  by  ethmoidal  or 
sphenoidal  sinuses,  ocular,  digestive,  gynecologic,  renal,  gouty, 
neurotic,  or  any  other  cause  except  empyema  of  the  frontal 
sinus. 

PROGNOSIS 

The  lorognosis  for  the  individual  case  is  difficult.  The  sim- 
plest treatment  is  sometimes  rewarded  by  a  strikingly  satis- 
factory result.  On  the  other  hand,  cases  that  would  apparently 
furnish  a  satisfactory  result  are  sometimes  found  to  be  most 
stubborn.  For  these  cases  everything  fails  save  the  removal  of 
the  middle  turbinate.  This  alone  frees  the  inlet  to  the  frontal 
sinus. 

The  prognosis  for  the  operated  case  will  ])e  found  to  vary 
according  to  the  microscopic  changes  in  the  turbinate  which 
has  been  removed.  If  it  shows  marked  periosteal  thickening 
and  bone  activity,  it  Avill  be  found  that  in  two,  three  or  five 
years  tlie  inlet  will  have  so  far  narrowed,  l)y  the  encroachment 
of  the  l3ulla  upon  the  uncinate  process  of  the  ethmoid,  that  the 
patient  will  again  have  pain  and  a  tender  Ewing's  point  dur- 
ing and  for  a  time  following  a  coryza ;  and  it  may  later  come  to 
pass  that  Ewing's  point  remains  tender  until  the  inlet  lias  again 
been  enlarged. 

On  the  other  liand,  cases  that  show  no  bone  or  periosteal 
activity  remain  apparently  permanently  cured. 

These  patients  usually  show  age  by  change  in  the  skin 
rather  than  change  of  features.  Tlieir  skin  will  look  old,  but 
their  features  in  fifteen  years'  time  sliow  almost  no  change. 

TREATMENT 

It  suggests  itself,  in  logical  sequence,  that  anything  that 
may  diminish  swelling  of  the  soft  tissues,  \^■hich  close  the  in- 


VACUUM    FRONTAL    HEADACHES  55 

let  to  the  sinus,  will  be  of  service,  and  to  this  end  I  have 
employed  the  various  astringents  in  commonplace  usage,  with 
satisfactory  results  for  a  very  great  number  of  cases,  the  appli- 
cations being  made  in  and  about  the  middle  meatus.  My  method 
of  procedure  is  to  try  these  applications  in  all  cases.  After  a 
trial  of  two  weeks,  if  there  has  not  been  any  response  to  treat- 
ment, more  radical  measures  may  ])e  resorted  to. 

It  is  sometimes  astonishing  to  see  what  may  l)e  accom- 
plished l)y  the  simple  application  of  astringents.  In  this  con- 
nection I  should  like  to  narrate  the  history  of  a  patient.  She 
had  sulfered  for  five  ^^ears  from  headaches  and  eye  disturb- 
ances. She  came  under  my  charge  in  1902.  Her  case  belonged 
in  Class  III.  Following  the  routine,  I  made  an  application  of 
2  per  cent  silver  nitrate  to  those  parts,  al)out  twelve  times, 
extending  over  a  period  of  three  weeks,  when  the  headache 
stopped,  and  has  not  returned.  I  state  this  positively,  because 
my  association  with  the  patient  socially  gives  me  full  oppor- 
tunity to  knoAV. 

It  is  well  known  that  the  obstruction  to  the  outfloAV  of  pus 
from  the  frontal  sinus  is  usually  the  middle  turbinate ;  and  so 
it  is  likewise  the  middle  turbinate  that  is  usually  the  obstruc- 
tion to  the  ingress  of  air  to  the  frontal  sinus. 

The  more  radical  treatment  is  then  the  opening  of  the 
inlet  of  the  frontal  sinus,  which  is  usually  accomplished  by  the 
removal  of  the  middle  turlnnate.  My  method  is  to  free  the 
inlet  to  the  anterior  laliyi-inth  of  the  ethmoid  at  the  same  time, 
removing  the  anterior  two-thirds  or  three-fourths  of  the  middle 
turbinate.  It  is  my  especial  effort  to  put  my  incision  as  high 
upon  the  capsule  of  the  ethmoid  (the  external  wall)  as  possible, 
about  2  mm.  from  the  cribriform  plate.  In  my  experience  this 
has  been  accomplished  most  readily  liy  the  method  I  described 
in  the  Journal  of  the  Americau  Medical  Association,  June  29, 
1907,  and  again  in  more  detail  and  elaboration,  before  the 
American  Laryngological  Association,  1916.  I  prefer  to  give 
this  technique  in  detail  in  connection  with  the  ethmoidal  sphe- 
noidal technique  in  Chapter  III,  page  164.  By  this  method 
the  turbinate  may  be  cut  out  up  into  the  infundibuluin.  This 
seems  to  me  also  to  be  necessary,  as  it  is  at  this  place  tliat  the 
o])struction  very  frequently  exists.     In  the  great  majority  of 


56  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGUST 

cases  this  suffices  to  open  the  sinus  and  thereby  effect  a  cure; 
the  headache  stops ;  and  the  eyes  go  into  unlimited  service. 

Three  times  I  have  found  the  uncinate  process  and  the 
bulla  of  the  ethmoid  in  a  firm  contact,  reaching  so  high  up  that 
I  Avas  obliged  to  remove  the  uncinate  process  up  to  the  level  of 
the  cribriform  plate,  and  once  some  little  above  it. 

Fifteen  times  I  found  the  hiatus  semilunaris  filled  out  by 
a  fibrous  hypertrophy  of  the  membrane  covering  the  bulla;  in 
these  cases  I  succeeded  in  getting  the  result  by  a  superficial 
galvanocautery  destruction,  the  line  of  Avhich  ran  parallel  to, 
and  just  posterior  to  the  uncinate  process.  The  contraction  of 
the  scar  resulting  from  this  wound  tends  to  pull  the  tissues 
out  of  the  hiatus  semilunaris. 

VACUUM  ETHMOIDAL  HEADACHES  WITH  EYE 
SYMPTOMS  ONLY 

Headache  may  arise  from  closure  of  the  anterior  labyrinth 
of  the  ethmoid,  and  is  in  every  way  similar  in  its  mode  of  estab- 
lishment to  the  frontal  sinus  headache  just  described.  This 
will  appear  from  a  perusal  of  the  anatomy  just  described.  It 
does  not,  however,  occur  anything  like  so  often.  The  tew  cases 
that  I  have  recognized  have  had  the  external  tender  point  at 
the  site  of  the  lacrimal  bone  instead  of  at  Swing's  point  and 
refer  the  pain  to  behind  or  between  the  eyes.  Use  of  the  eyes 
is  not  so  much  a  factor  in  making  the  headache  in  these  cases 
as  in  the  frontal  sinus  cases.  Considering  the  anatomy  in  the 
light  of  the  description  just  given  it  is  somewhat  surprising 
that  they  do  not  arise  oftener,  especially  from  the  cells  which 
so  often  open  into  the  infundil)ulum  and  hiatus  semilunaris. 

The  pathology,  diagnosis,  prognosis,  and  treatment  in  these 
cases  are  otherwise  the  same  as  for  the  frontal  sinus  cases. 

The  outlet  of  the  maxillary  antrum  in  the  hiatus  semi- 
lunaris is  so  placed  as  to  render  it  possible  of  closure  under 
the  same  influences  that  close  the  frontal  and  anterior  ethmoidal 
cells.  I  have  not,  however,  ever  seen  a  case  that  seemed  to  me 
to  be  such.  I  have  construed  this  as  explicable  by  virtue  of 
the  fact  that  the  walls  of  the  antrum  are  thick  and  do  not  be- 
come sensitive  under  these  conditions.  Nevertheless,  T  can  con- 
ceive of  such  a  case,  and,  moreover,  R.  C.  Lyncli^'  has  reported 
a  numl)er  of  them. 


CHAPTER  II 

THE  SYNDROME  OF  NASAL*  (SPHENOPALATINE— 
]\tECKEL'S)  GANGLION  NEUROSIS 

In  1908  I'°  called  attontion  to  a  set  of  neuralgic  phenomena 
that  in  my  opinion  were  prodnced  hy  lesions  affecting  the  nasal 
ganglion.  Since  then  in  several  articles  I  have  recorded  motor, 
sensory,  gustatory,'^-  "-•  '^  ocular,  respiratory  and  sympathetic^* 
(vasomotor  and  secretory),  phenomena  atti-il)utal)le  to  the 
same  causes. 

It  is  my  desire  in  this  essay  to  present  fully  the  various 
manifestations  of  nasal  ganglion  neurosis  as  far  as  I  know  them 
at  present,  and  to  call  attention  to  the  anatomy  of  the  district 
in  which  the  ganglion  is  found.  So  far  as  I  can  determine,  the 
histology  of  ganglion  in  man  has  not  been  observed. 

ANATOMY** 

The  Nasal  Ganglion. — The  sphenopalatine  ganglion  (g. 
sphenopalatinum),  also  known  as  Meckel's,  the  sphenomaxil- 
lary or  the  nasal  ganglion,  is  a  small  triangular  reddish-gray 
body,  with  the  apex  backward,  situated  in  the  upper  portion 
of  the  sphenomaxillary  fossa.  It  is  flat  on  its  mesial  surface, 
and  convex  on  its  lateral,  and  measures  about  5  mm.  in  length. 
It  lies  in  close  proximity  to  the  sphenopalatine  foramen  and 
just  beneath  the  maxillary  branch  of  the  trigeminal  nerve.  The 
ganglion  is  regarded  as  belonging  to  the  series  of  sympatlictic 
nodes  and  consists  of  an  interlacement  of  nerve-fibres  in  which 
are  embedded  numerous  stellate  sympathetic  neurones. 

Roots. — The  sensory  root  consists  of  two,  sometimes  three, 
short  stout  iilaments,  the  sphenopalatine  nerves  (nn.  spheno- 
palatini),  which  pass  directly  downward  from  tlie  lower  mar- 
gin of  the  maxillai'y  nerve  to  the  upper  bordei-  ol'  tlic  ganglion. 

*The  term  "Nasal  Ganglion"  is  used  by  authoritative  anatomists  at  the  present  day, 
although  the  "Nomina  Anatomica"  accepted  by  the  Anatomical  Society  at  Basel  in  1895 
(B.  N.  A.)  included  that  of  Sphenopalatine  Ganglion  only.  I  prefer  the  term  "Nasal  Gan- 
glion"  V)ecause   it   directs  the   clinician   more   readily. 

**This  description  is   taken   from   Piersol"''  and   Ouain."'' 


58  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIlSr 

AVliilo  some  few  of  the  fil^res  of  this  root  are  axoiies  of  the 
sympathetic  ganglion-eells,  tlie  great  majority  are  dendrites  of 
the  cells  of  the  Gasseriaii  ganglion  which  pass  to  a  limited  ex- 
tent through,  bnt  mostly  around  the  sphenopalatine  ganglion 
independently  of  its  cellular  elements.  They  are  continued 
entirely  into  the  various  trunks  that  are  usually  described  as 
branches  of  distribution  of  the  ganglion. 

The  motor  root  is  the  great  superficial  petrosal  nerve  (n. 
petrosus  superficialis  major)  whicb  in  all  probability  carries 
sensory  as  well  as  motor  fibres.  It  arises  from  the  facial  nerve 
in  the  facial  canal,  passes  through  the  hiatus  Fallopii  and  a 
groove  in  the  petrous  portion  of  the  temporal  bone  and  then 
under  the  Gasserian  ganglion  to  reach  the  cartilage  occupying 
the  middle  lacerated  foramen.  Here  the  great  superficial 
petrosal  nerve  is  joined  by  the  sympathetic  root,  the  great  deep 
petrosal  (n.  petrosus  profundus),  Avliich  is  a  branch  from  the 
carotid  plexus.  The  two  great  petrosal  nerves  fuse  over  the 
cartilage  at  the  middle  lacerated  foramen  to  form  the  Vidian 
nerve  (n.  canalis  pterygoidei  [Vidii] )  which  traverses  the  canal 
of  the  same  name  and  enters  the  sphenomaxillary  fossa  to  join 
the  nasal  ganglion.  In  its  course  through  the  canal  the  Vidian 
nerve  gives  off  a  few  small  nasal  ])ranches,  which,  composed  of 
trigeminal  and  sympathetic  filires,  supply  the  phar^^igeal  os- 
tium of  the  Eustachian  tul)e  and  the  posterior  part  of  the  roof 
of  the  nose  and  the  nasal  septum.  While  in  the  canal,  the  Vid- 
ian nerve  I'eceives  a  filament  from  the  otic  ganglion. 

Branches. — The  l)ranclies  of  distribution  of  the  nasal  gan- 
glion are  conveniently  grouped  into  four  sets:  (1)  the  ascending, 
(2)  the  descending,  (3)  the  internal  and  (4)  the  posterior. 
(Fig.  34.) 

1.  The  ascending  or  orbital  branches  (nn.  orbitalis)  are 
two  or  three  small  filaments,  which  pass  into  the  orbit  through 
the  sphenomaxillary  fissure  and,  after  traversing  the  posterior 
ethmoidal  canal  or  a  small  special  aperture,  are  distril)uted 
to  the  sphenoidal  and  ^Dosterior  ethmoidal  air-cells  and  the  peri- 
osteum of  the  orbit. 

2.  The  descending  branches  (nn.  palatini)  are  three:  (a) 
the  large  posterior  palatine,  (h)  the  posterior  palatine,  and  (c) 
the  accessory  posterior  palatine  nerves. 


SYXDROME    OF    NASAL    GAXGLIOX    XEUROSIS 


59 


a.  The  large  posterior  palatine  nerve  (n.  palatinns  poste- 
rior) leaves  the  sphenomaxillary  fossa  by  means  of  the  large 
posterior  palatine  canal,  through  whieli  it  descends  to  the  infe- 
rior surface  of  the  hard  palate.  While  in  the  canal,  it  gives  off 
one  or  two  posterior  inferior  nasal  branches  (nn.  nasales  pos- 
teriores  inferiores),  which  escaping  tlirough  small  apertures 
in  the  perpendicular  plate  of  the  palate  ])one,  enter  the  nasal 
fossa  and  supply  the  nuicous  membrane  of  all  but  the  anterior 
portion  of  the  inferior  turbinate  bone  and  the  adjoining  por- 
tions of  the  middle  and  inferior  meatuses.  Emerging  from  its 
canal  the  main  nerve  passes  forward  in  a  groove  on  the  inferior 


Fig.   34. — I.  Nasal   ganglion. 


\'idian    nerve. 


alatal    branches.      (After   Ouain.) 


aspect  of  the  hard  palate  and  inosculates  with  the  terminal 
filaments  of  the  nasopalatine  nerve.  It  supplies  the  liard  pal- 
ate and  its  mucous  membrane,  as  well  as  the  inner  side  of 
the  gum. 

b.  The  small  posterior  palatine  nerve  (n.  palatinus  pos- 
terior) descends  in  the  small  posterior  palatine  canal.  It  sup- 
plies sensory  filaments  to  the  mucous  membrane  of  the  soft 
palate  and  the  tonsil  and  motor  ones  to  the  levator  palati  and 
azygos  u\ailae  muscles. 

c.  The  accessory  posterior  palatine  nerves  (nn.  palatinus 
medius),  are  one  or  more  small  filaments  which  pass  through 
the  accessory  posterior  palatine  canals  and  su])i)ly  tlie  nuicous 
membrane  of  the  soft  palate  and  tonsil. 

3.  The  internal  brandies   (nn.  nasales  postei'iores  superi- 


60  HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN 

ores)  pass  from  the  sphenomaxillary  into  the  nasal  fossa 
through  the  sphenopalatine  foramen.  They  are:  {a)  the  pos- 
terior superior  nasal  and  (/;)  nasopalatine  nerve, 

a.  The  posterior  superior  nasal  nerve  (r.n.  laterales),  sup- 
plies the  mucous  membrane  of  the  posterior  superior  portion 
of  the  outer  wall  of  the  nasal  fossa. 

h.  The  nasopalatine  nerve  (n.  nasopalatinus),  crosses  the 
roof  of  the  nasal  chamber  and  passes  downward  and  forward 
in  a  groove  in  the  vomer  and  septal  cartilage  to  reach  the  an- 
terior palatine  canal.  It  then  passes  through  the  foramen  of 
Scarpa,  the  left  nerve  through  the  anterior  and  the  right  one 
through  the  posterior  canal,  the  two  nerves  forming  in  this 
situation  a  fine  plexus.  Having  reached  the  inferior  surface  of 
the  hard  palate,  the  nasopalatine  inosculates  with  the  large  pos- 
terior palatine  nerve.  It  supplies  the  roof  and  septum  of  the 
nose  and  that  portion  of  the  hard  palate  which  lies  posterior 
to  the  incisor  teeth.  (Fig.  34). 

4.  The  posterior  l)rauch,  also  known  as  the  pharyngeal  or 
pterygopalatine,  leaves  the  sphenomaxillary  fossa  through  the 
pterygopalatine  canal  and  supplies  the  mucous  membrane  of 
the  nasopharynx  in  the  region  of  the  fossa  of  Rosenmiiller. 

Variations. — Branches  of  the  ganglion  have  been  described 
as  passing  to  the  al)ducent  nerve,  to  the  ciliary  ganglion  and  to 
the  optic  nerve  or  its  sheath.  The  accessory  posterior  palatine 
nerve  is  sometimes  absent.  Quite  frecpiently  the  left  naso- 
palatine nerve  passes  through  the  posterior  foramen  of  Scarpa 
and  the  right  nerve  through  the  anterior.  In  addition  to  sup- 
plying (according  to  many  anatomists)  motor  fibres  to  levator 
palati  and  azygos  u^^ulae  muscles,  some  of  the  facial  fibres  are 
especially  destined  for  glandular  structures.  Such  fil^res  are 
probably  interrupted  around  the  stellate  cells  of  the  nasal 
ganglion,  the  axones  of  which  then  complete  the  paths  for  the 
secretory  impulses.  The  sensory  constituents  of  the  great 
superficial  petrosal  nerve  are,  perhaps,  of  two  kinds;  (a)  fibres 
from  the  cells  of  the  geniculate  ganglion  of  the  facial  to  the 
palatine  taste  buds,  and  (h)  recurrent  trigeminal  fibres,  that, 
by  way  of  the  maxillary,  sphenopalatine  and  great  super- 
ficial petrosal  nerves,  are  distributed  with  the  peripheral 
branches  of  the  A'idian  or  of  the  facial  nerve. 


SYXDEOME    OF    XASAL    GANGLION    NEUROi^IS  61 

The  great  deep  petrosal  nerve  represents  the  association 
oord  Ijetween  the  superior  cervical  sympathetic  and  the  nasal 
ganglion.  Many  of  its  filires  end  in  arborizations  ai'onnd  the 
stellate  nasal  ganglion  cells,  from  which,  in  tnrri,  axones  pass 
to  Ijlood-vessels  and  glands  by  way  of  the  ganglionic  branches 
of  distribution. 

The  environuicvf  of  the  ganglion  is  of  the  greatest  impor- 
tance for  the  clinician.  No  mention  of  it  has  been  made  more 
than  ''it  lies  deep  in  the  sphenomaxillary  fossa"  or  "close  to 
thc^  sphenopalatine  foramen.'' 

Anatomical  Relations. — Tlie  treatises  on  anatomy  describe 
the  nasal  (sphenopalatine-Meckel's)  ganglion  "as  lying  in  the 
sphenomaxillary  fossa  close  to  the  sphenopalatine  foramen." 
(Quain,  Piersol,  and  others.)  The  sphenomaxillary  fossa  is 
described  as  "formed  a])ove  by  the  under  surface  of  the  body 
of  the  sphenoid  and  the  orbital  process  of  the  palate  bone;  in 
front,  l)y  the  superior  maxillary  lione;  liehind,  by  the  anterior 
surface  of  the  base  of  the  pterygoid  process  and  lower  part  of 
the  anterior  surface  of  the  great  wing  of  the  s])hen()id;  inter- 
nally, by  the  vertical  plate  of  the  palate."* 

Neither  this  description  nor  any  found  in  other  textbooks 
on  anatomy  suggests  any  close  relation  of  tlie  nasal  ganglion 
to  the  nose  or  the  paranasal  cells  (sinuses)  ;  nor  do  the  special 
treatises  upon  the  nose  make  mention  of  such  relation.  As  a 
fact,  however,  the  nasal  ganglion  lies  very  close  to  the  lateral 
l)ony  wall  of  the  nose,  in  A\"hich  the  sphenopalatine  foramen 
occurs  as  a  small  deficiency  at  its  upper  posterior  part.  By 
actual  measurement  the  nasal  ganglion  frecpiently  lies  as  close 
as  one  or  two  millimetres  from  the  nasal  mucous  membrane; 
it  may  lie  as  deep  as  seven  or  even  nine  millimetres.  Krause,''*' 
whose  text  was  found  after  the  preceding  observations  were 
made,  states  that  it  is  sometimes  two  ganglia,  one  suspended  on 
each  sphenopalatine  nerve.  He  also  states  that  it  sometimes 
projects  through  the  sphenopalatine  foramen  to  lie  submucous 
to  the  nose. 

The  current  descriptions  of  the  sphenomaxillary  fossa  give 
the  impression  of  its  being  surrounded  Ijy  solid  bones.  This 
also    is    misleading.      More    comprehensively,    tlie    description 


*This   descrii)tion    is   taken    from   (iray's   Anatomy,    1S96. 


62 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL,    ORIGIN 


"formed  above  by  tlie  under  surface  of  the  body  of  the  sphenoid 
and  the  orbital  process  of  the  palate  bone"'  means  that  it  is 
bomided  above  by  the  walls  of  the  splienoidal  sinus,  including 
the  sphenoidal  process  of  the  palate  bone  closing  it,  and  that 


Fig.  35. — Showing  S])henoi)a!atine  foramen  /  liounded  aliove  by  splienoidal  sinus  _■?,  and 
In  front  by  ethmoidal  cells  2  and  4.  The  sphenoiialatine  foramen  is  in  the  inner  limit  of  the 
sphenomaxillary   fossa. 


the  seyparatinfj  icall  is  a  thin  one.  The  description  "in  front, 
by  the  superior  maxillary  bone,"  means  that  it  is  bounded  in 
front  by  the  wall  of  the  maxiUarij  sinus  and  that  this  Avail  too 
is  of  thin  bone.  The  description  "behind,  by  the  anterior  sur- 
face of  the  great  wing  of  tlie  sphenoid"  means  that  this  wall 
also  is,  in  some  cases,  only  a  tliin  plate  separating  the  fossa 


SYXDROME    OF    NASAL    GANGLION    NEUROSIS 


63 


from  a  doivnirard  prolan (jat ion  of  the  sphenoidal  si)n(s  into  the 
pterygoid  process  and  into  the  great  wing;  a  condition  which  is 
not  nncommon,  although  in  tlie  majority  of  cases  the  pterygoid 
process  is  of  solid  bone. 

The  outer  aspect  of  the  sphenomaxillary  fossa  is  then  the 
only  one  that  is  not  in  intimate  association  ^vitli  the  cavity  of 
the  nose  or  the  paranasal  cells. 

It  seems  essential  that  in  a  comprehensive  description  of 


Sinus  frontal  I 


Celltiiie  eth-moidaiej   fentcnorcsy 

Cellulae     cthmoicliJes   (posteriorcJ  \        " 

Nervus  opticu. 


sphcTiopalckL 


Sinus  sphenoidji,: 


iTocessus 
pterya;oideu. 


iinus  majtiMan 


^accus  ls.crim.2i.lib 


, Ostium,  maxilldj-e. 


Fig.    36. — Sagittal    section    7    mm.    lateral    to    the    sphenopalatine    foramen.       (Specimen    decalcitied 

in    hydrochloric   acid.) 

these  parts  special  emphasis  should  he  hiid  ii])on  their  intimate 
relations  to  the  nose  and  paranasal  cells. 

The  variations  of  the  paranasal  cells  ought  also  to  be 
studied  in  detail :  The  sphenoidal  sinus  may  form  the  entire 
upper  l)oundary  of  the  sphenomaxillary  fossa.  (Fig.  35.)  The 
sphenoidal  sinus  may  also  form  the  posterior  boundary  of  the 
sphenomaxillary  fossa  as  a  result  of  its  being  prolonged  down- 


64 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


ward  into  the  pterygoid  process  and  great  wing  (Fig.  36).  A 
post-etlimoidal  cell  may  bonnd  the  anterior  half  of  the  upper 
part  of  fossa  (Fig.  35).  The  sphenoidal  sinus  may  be  extended 
downward  and  forward  to  form  the  upper  half  of  the  anterior 
Iboundary  of  the  fossa  (Fig.  37).  The  wall  of  the  nose  may 
curve  so  shdrpljj  o)ifu-ard  as  to  form  a  part  of  the  anterior 
houudaru  of  the  fossa. 

The  nasal  ganglion  lies  high  up  in  the  sphenomaxillary 
fossa.  It  is  ai)pareiitly  prolonged  backward  into  the  Vidian 
(pterygoid)  nerve.    (Quain,  Anatomij,  1897.)     (Fig.  38.)    There 


Pig.   37. — Showing   left    sphenoidali   sinus   /,    prolonged    downward    iti    front    to    form    the    anterior 
wall   of  the  sphenomaxillary   fossa   }.      2.    Right   sphenoidal   sinus. 


is  usually  a  marking  upon  the  bone  corresponding  to  this ;  a  well- 
uiodeled  funneling  at  tlie  anterior  end  of  the  canal  (Fig.  39). 

Relations  of  the  Nasal  Ganglion  in  the  Sphenomaxillary 
Fossa. — The  ganglion  lies  close  to  the  top  of  the  splienomaxil- 
lary  fossa.     (All  textbooks  are  agreed  upon  this  point.)     In 


SYXDEOME    OF    NASAL    GAXGLIO]Sr    NEUROSIS 


65 


front  the  ganglion  is  in  relation  with  the  arteria  palatina  de- 
scenclens  and  arteria  sphenopalatina  and  with  the  correspond- 
ing veins.  These  vessels,  with  some  surrounding  connective 
tissue,  form  a  separation  of  3  or  4  mm,  from  the  wall  of  the 
maxillary  sinus, — the  anterior  boundary  of  the  fossa. 

The  Relations  of  the  Nasal  Ganglion  to  the  Walls  of  the 
Paranasal  Cells. — When  tlie  upper  boundary  of  tlie  fossa    is 


>ellulae   ethmoidales  (aotenores) 

Celiulb.e    ethrrvoidales    (posteriores^ 
Nervus   opticus 
^inuh  sphenoicizJis 


/  descendena  . 

.gflipn  sphcro 
a»l6.tinurn 


ra.lo.t»um,     duru 


\a.ud)ttyc 

[Lvi5t,acK\i] 


"onchcx  •n.Exso.lis    inferior  , 
Fig.  38. 

made  wholly  by  the  sphenoidal  sinus,  the  ganglion  lies  in  close 
relation  to  the  sphenoidal  sinus.  AVhen  the  upper  boundary  of 
the  fossa  is  made  by  the  sphenoidal  sinus  in  its  posterior  half 
and  by  a  post-ethmoidal  cell  in  its  anterior  half,  the  ganglion 
lies  in  close  relation  to  both.  "Wlien  the  sphenoidal  sinus  is 
prolonged  downward  and  forward  the  ganglion  will  lie  in  close 


66  HEADACHES    AND    EYE    DISOEDERS    OF    NASAL    ORIGIN 

relation  to  it  in  front.  AVhen  the  sphenoidal  sinus  is  prolonged 
downward  into  the  pterygoid  process,  the  ganglion  will  then 
lie  posteriorly  in  close  relation  to  the  sphenoidal  sinns.  Fig.  37 
shows  a  specimen  in  which  the  ganglion  is  in  close  relation  to 
the  sphenoidal  sinus  anteriorly,  superiorly,  and  posteriorly. 

Anteriorly  the  fcssa  is  formed  by  the  wall  of  the  maxillary 
sinus.  But  the  ganglion  can  never  lie  in  close  relationship  to 
this  wall  because  of  the  pad  formed  by  the  arteria  palatina 
descendens  and  the  arteria  sphenopalatine  with  their  accom- 
panjdng  veins  and  surrounding  connective  tissue  (Fig.  40). 

The  Relation  of  the  Nasal  Ganglion  to  the  Lateral  Wall  of 
the  Nose. — The  sphenopalatine  foramen  is  accurately  placed  at 
a  point  just  posterior  to  and  immediately  above  the  posterior 


Fig.   39. — Showing    anterior    face    of    right    pterygoid    process.       I.   Foramen     rotundum.       s.  An- 
terior   outlet    of    Vidian    canal. 

tip  of  the  middle  turl)inate.  The  ganglion  usually  lies  close 
to  the  plane  of  this  foramen.     (Fig.  41.) 

The  ganglion  does  not,  however,  always  show  the  same 
relation  to  the  foramen.  I  have  found  it  as  close  as  one  or  two 
millimetres  from  the  general  membrane  of  the  nose,  and  as  far 
as  nine  millimetres.  I  have  found  the  variation  in  the  position 
of  the  ganglion,  whether  higher  or  lower,  to  be  very  slight. 

The  sphenomaxillary  fossa  considered  from  this  point  of 
view  is  seen  to  resemble — is  tantamount  to — a  paranasal  cell. 
It  is,  however,  not  closed  externally  by  nasal  tissues  and  is 
filled  by  the  before-mentioned  structures  with  their  accompany- 
ing connective  tissue  instead  of  air.  Below  it  is  closed  by  the 
apposition  of  its  anterior  and  posterior  walls. 

Clinical  Relations. — With  sucli  intimate  anatomical  asso- 
ciation, clinical  manifestations  from  the  extension  of  inflamma- 


SYNDROME    OF    NASAL    GANGLION    NEUROSIS 


67 


tioii  ill  the  nasal  fossa  or  its  products  would  seem  of  almost 
necessary  occurrence.  The  nasal  ganglion  is,  in  fact,  in  quite 
as  close  relation  to  the  nose  and  the  paranasal  cells  as  is  the 
optic  nerve.  It  has  long  been  recognized  that  inflammatory 
processes  in  the  sphenoidal  and  post-ethmoidal  sinuses  extend 
to  the  optic  nerve,  and  this  fact  has  heen  demonstrated  post- 
mortem by  Birsch,  Hirschfeld,*  and  Uffenorde,t  and  possibly 
others.  I  also  have  seen  lesions  on  the  optic  canal  in  life  by 
means  of  Holmes '^""^  nasopharyngoscope  (page  118),  illustrating 


3inus  frontalis . 

ellulac  etVimoidiles   Cariteri  ores) 


Saccus    lacrim^lii 


pellulac    £tKruoidales  Cposterlores) 
Nei-vus   opticus. 

Sinus  sphenoidalis  ■ 
A.  palalina    descendens . 
--Ganglion.  spKenopalsitiRum 
sphenopalalina  ■ 
l_^^an&lis  pterygoideus  IVidiiJ  , 
pTcrygopal^Ilna.  . 

— -^.R-ocessus    pterYSoidcus . 


Sinus  TTtaxillarL 


Paldtuim    duru 


ics  lateralis  cavi  aasi  - 


Fig.   40.— Sagittal    section    3    mm.    lateral    to    the    sphenopalatine    foramen.       (Specimen    decalcified 
in   hydrochloric   acid.)      Showing   a   dissection   of   the   sphenopalatine   fossa. 

this  fact  in  a  most  striking  manner  botli  at  the  time  of  opening 
the  sphenoid  and  as  subsequent  phenomena  in  the  course  of 
the  case.  It  is  therefore  altogether  reasonable  to  assume  that 
these  processes  also  pass  over  to  the  nasal  ganglion,  although 
the  clinical  picture  is  very  much  less  evident  than  the  blindness 
produced  by  involvement  of  the  optic  nerve. 

According  to  my  observation,  characteristic    disturbances 


*Graefe's  Archiv,   190". 
tZeitschrift  f.  Laryng.,  vol.  iii. 


bo  HEADACHES    A:NtD    EYE    DISORDERS    OF    iSTASAL    ORIGIN 

have  followed  post-etlimoida]  and  sphenoidal  suppurative  in- 
flammations which  cannot  he  explained  otherwise  than  hy  as- 
suming that  the  nasal  ganglion  has  hecome  involved  hy  exten- 
sion ;  some  of  these  disturhances  have  heen  transitory,  and 
some  have  persisted  for  many  years.  In  other  cases  the  convic- 
tion has  heen  equally  positive  that  the  extension  has  heen  from 
the  nose  proper.     Thus  far,  I  have  not  seen  anything  that  1 


Fig.   41. — Showing    /     middle     turbinate.       2.    Sphenopalatine     foramen     directly     posterior     to     and 
slightly   above    posterior   tip    of   middle    turbinate. 


could  interpret  as  an  extension  from  the  maxillary  sinus.  From 
the  anatomical  relations  of  the  nasal  ganglion  to  the  anterior 
boundary  of  the  sphenomaxillary  fossa,  i.  e.,  to  the  posterior 
wall  of  the  maxillary  sinus,  I  do  not  believe  that  it  is  at  all 
likely  to  he  involved  by  extension  of  an  inflammatory  process 
from  that  sinus,  inasnnich  as  the  arteria  palatina  descendens 
and  the  arteria  sphenopalatina,  together  with  their  accompany- 


SY^STDROME    OF    XASAL    GANGLIOX    NEUROSIS  69 

ing  veins  and  the  siii'i'onnding  connective  tissne,  lie  between  the 
g-anglion  behind,  and  the  wall  of  the  maxillary  sinns  in  front. 
This  relation  appears  to  he  constant;  and,  T  believe,  explains 
why  clinical  manifestations  referable  to  the  ganglion  do  not 
ordinarily  follow  inflannnatory  processes  in  the  maxillary  sinns. 
Fnrthermore,  pns  in  the  maxillary  sinns  will  remain  much 
below  this  level,  which  may  possibly  be  another  factor  in  the 
explanation. 

During  1907  I  saw  a  number  of  cases  of  acute  suppurative 
inflammation,  of  grippe  origin,  in  the  sphenoidal  and  post- 
ethmoidal  cells,  which  got  well  of  the  suppuration  in  from  three 
to  four  weeks,  but  in  which  pain  still  remained  which  seemed 
neuralgic  in  nature.  (Sometimes  the  neuralgic  manifestations 
arose  a  few  days  after  the  inflammatory  onset.)  The  peculiar 
dull  pain  of  the  suppurating  splienoid  referred  to  the  occiput, 
or  the  post-ethmoidal  cells  referred  to  the  parietal  eminence, 
usually  preceded  these  neuralgic  phenomena.  In  1914  I^*  rec- 
ognized a  symptom-complex  referable  to  tlie  sympathetic  auto- 
nomic elements  of  the  ganglion.  In  a  preliminary  report,^" 
based  on  ten  cases,  I  desci-ibed  certain  of  these  manifestations; 
now,  after  an  observation  of  several  hundred  cases,  it  is  pos- 
sible to  draw  a  more  complete  clinical  picture. 

The  Neuralgic  Sjrndrome  v/ith  the  Usual  Forerunner 

A  patient  presenting  all  the  features  will  tell  of  a  coryza  of 
lesser  or  greater  severity — sometimes  astonishingly  slight  and 
often  forgotten,  or,  it  may  have  produced  a  post-ethmoidal-sphe- 
noidal  empyema  of  greatest  intensity.  A  short  time  later,  pain 
began  at  the  root  of  the  nose,  in  and  al)Out  the  eye,  the  upper 
jaw  and  teeth,  sometimes  also  the  lower  jaw  and  teeth,  and  ex- 
tending backward  to  tlie  temple  and  about  the  zygoma  to  the 
ear,  making  earache;  emphasized  at  the  mastoid,  but  always 
severest  at  a  -point  5  cm.  hack  of  that ;  thence  reaching  l)ackward 
by  way  of  the  occiput  and  neck,  it  may  extend  to  the  shoulder 
blade  and  shoulder  (less  often  to  the  axilla  and  breast),  and 
in  severe  attacks  to  the  arm,  forearm,  hand,  and  even  the  finger 
tips.  This  is  the  most  frequent  i)icture,  but  at  times  there  may 
be  also  a  sense  of  "stiff"  or  "aching"  throat;  or  of  pain 
(oftener  itching)  in  the  hard  palate;  oi'  ])ain  inside  the  nasal 


70  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN" 

fossae;  or  a  feeling  that  the  teeth  are  "too  long";  or  a  per- 
verse (inetallic)  sense  of  taste  (parageusia)  (rare)  or  seotoma 
scintillans  (rare)  or  salivation  (rare).  Itching  of  the  shoulders 
has  also  been  observed.  The  sense  of  taste  is  slightly  less  acute 
over  the  anterior  two-thirds  of  the  tongue  on  the  affected  side. 
Rarely,  in  the  beginning  or  at  the  height  of  the  attack  it  is 
slightly  more  acute.  The  arch  of  the  soft  palate  is  higher  on 
the  affected  side ;  the  uvula  and  dimple  which  forms  above  it 
on  gagging  are  deflected  to  the  well  side.  A  slight  blunting  of 
sensation  is  found  in  the  nose  and  throat  as  far  down  as  the 
tonsil  on  the  affected  side.  There  may  be  a  sense  of  stuify 
ears,  Avhich  are .  easily  inflated  with  but  short  relief.  I  have 
construed  these  as  tubes  which  are  not  opened  normally  by 
the  levator  palati;  and  that  this  happens  because  the  motor 
function  from  the  ganglion  is  lessened  at  the  time  of  the  attack 
of  pain.  As  the  pain  subsides  this  symptom  disappears.  Itch- 
ing of  the  upper  extremity  has  been  observed.  Mild  cases  are 
described  as  a  sense  of  tension  in  the  face  and  stiffness  or 
"rheumatism"  in  the  shoulders  and  neck.  The  ganglion  is 
accessible  for  cocainization  which  relieves  the  pain. 

The  Sympathetic  Syndrome. — The  al)ove  described  picture 
is  sometimes  supph'ineiitcd  l)y  a  sympathetic  syndrome  very 
wide  in  its  distribution  and  wondrously  complex,  a  prominent 
part  lieiiig  vasomotor  and  secretory  phenomena.  And  some- 
times it  happens  that  these  are  the  o)ilu  symptoms  of  disturb- 
ance in  the  nasal  ganglion.  I  think,  liowever,  that  the  sympa- 
thetic syndrome  occurs  less  often  than  the  painful  sjmdrome. 
But  a  sharp  division  is  impossible  l)ecause  the  sympathetic 
plays  a  prominent  part  in  the  pain  complexes  also.  The  same 
etiology  is  found. 

Inflammation  of  more  or  less  severity  in  the  district,  usu- 
ally has  preceded  the  vasomotor-secretory  phenomena.  They 
may  be  aroused  by  a  sliglit  coryza  that  has  had  little  time  for 
development,  and  appear  Avith  explosive  effect,  out  of  propor- 
tion to  the  pathological  lesion.  The  patient  in  health  is  for  the 
first  time,  regardless  of  the  season  of  the  year,  seized  Avith  se- 
vere and  protracted  sneezing  accompanied  by  much  nasal  con- 
gestion and  thin  hot  secretion,  so  profuse  at  times  as  to  have 
him  resort  to  a  towel  for  use  as  a  handkerchief.     With  the 


SYiS^DROME    OF    XASAL    GAXGLIOX    NEUROSIS  71 

great  congestion  of  the  nasal  fossae  is  found  great  sensitiveness 
of  the  internal  nose,  with  great  redness  (congestion)  and  swell- 
ing of  the  external  nose,  and  soon  thereafter,  may  appear  more 
or  less  ronghing  of  the  skin  from  the  secretion  and  the  wiping 
it  necessitates.  In  addition  to  these  symptoms,  the  eyes  are 
greatly  reddened  (congestion  of  the  conjunctiva)  and  bathed 
in  tears  of  a  profusion  corresponding  to  the  nasal  secretion, 
accompanied  by  dilatation  of  the  pupil  and  the  appearance  of 
staring.  The  lids  are  wide  open,  giving  the  appearance  of 
prominent  eyes.  (One  case  had  a  slight  exophthalmos.)  They 
are  involved  almost  if  not  quite  simultaneously  with  the  nose. 
A  sense  of  itching  or  burning,  or  a  feeling  of  wind  blowing  into 
them  accompanies  the  lacrimation,  together  with  a  feeling  of 
discomfort  of  a  peculiar  kind  which  seems  independent  of  the 
secretion  and  congestion;  and  there  may  be  the  greatest  photo- 
phol)ia  or  sense  of  intense  light  when  no  light  at  all  is  present. 
Work  recpiiring  near  vision  is  usually  very  difficult  or  not  pos- 
sible under  these  conditions.  Sometimes  these  s^miptoms  are 
accompanied  by  dyspnea  Avith  dry  rales  (asthma). 

Tliis  description  in  the  main  is  at  once  recognized  l^y  rhi- 
nologists  as  "the  terrible  or  terrific  cold"  which  has  been  de- 
scribed with  great  emphasis  by  patients  from  time  to  time. 
For  a  number  of  years  I  have  thought  that  these  were  symp- 
toms on  the  part  of  the  sympathetic  which  supplies  the  nasal 
ganglion,  and  felt  tliat  cocaine  could  be  used  to  control  them. 
Various  other  thoughts  prevented  me  from  drawing  conclusions 
from  cases  of  longer  standing  (vasomotor  rhinitis,  hay  fever, 
paroxysmal  sneezing,  rhinitis  nervosa).  During  the  recent 
past,  however,  I  have  had  these  cases  so  acute  and  so  severe 
that  they  seemed  perfect  for  the  experiment.  The  nasal  gan- 
glion was  cocainized  usually  from  its  internal  aspect,  that  is, 
the  sphenopalatine  foramen — the  side  from  Avhich  the  Vidian 
enters.  One-half  of  one  drop  saturated  watery  solution  (90%) 
was  applied,  sometimes  once  only,  and  sometimes  repeated. 
The  effect  was  to  quickly  stop  the  secretion  in  the  nose  and  eyes 
and  bring  them  back  to  normal  appearance.  The  swollen,  red 
nose  (rosacea)  and  the  puffed,  red,  disabled,  staring,  tearing 
eyes  became  normal,  and  likewise  the  nasal  fossae;  and  the 
photophobia  ceased;  and  the  pupils  contracted. 


72  PIEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIIST 

Further  experience  revealed  that  these  cases  in  their  be- 
havior to  cocaine  were  not  unlike  the  painful  ones  arising  from 
the  ganglion,  Cocainization  (once)  was  curative  for  those  that 
were  provoked  by  a  slight  inflammatory  condition.  Those  aris- 
ing in  the  wake  of  more  pronounced  change — post-ethmoidal- 
sphenoiclal  inflammations — but  of  short  duration,  often  yielded 
to  a  few  applications  repeated  from  day  to  day.  Two  per  cent 
silver  nitrate  and  1  per  cent  formalin  are  helpful  in  older  cases. 
Severe,  long-standing  cases  were  sometimes  not  helped  by  any- 
thing short  of  injection  and  then  A^ery  little  or  not  at  all  by 
one  injection.  They  required  reinjection.  A  considerable  per- 
centage of  the  ordinary  coryzas  is  of  this  type.  Deep  infection 
of  the  membrane  which  leads  to  suppuration  of  the  sinuses  is 
of  course  not  to  be  classed  with  these  cases.  When  the  sympa- 
thetic attributes  (vasomotor,  secretory,  etc.),  are  once  added  to 
the  picture  they  are  very  apt  to  recur  more  or  less  marked  iij 
subsequent  coryzas. 

When  the  case  lasts  a  little  longer,  the  paroxysms  begin  to 
appear  irregularly  and  often  settle  doA\Ti  into  the  morning 
sneezing  of  "rhinitis  nervosa."  The  clinical  course  of  a  given 
case  may  be  of  the  sympathetic  type  pure,  but  upon  questioning 
closely,  it  is  very  often  found  that  a  Ioav  grade  ganglion  neu- 
ralgic complement  exists  which  the  patient  often  refuses  to 
have  connected  with  his  nasal  disturbances.  He  maintains  that 
his  head,  neck,  shoulder,  etc.,  pains,  are  "rheumatism,"  or 
"stiff  muscles"  or  "neuritis"  or  some  one  of  a  dozen  explana- 
tions which  are  absolutely  satisfactory  to  him  and  about  which 
he  does  not  want  to  have  his  mind  changed.  Following  these 
cases  further,  it  appears  that  the  syndrome  becomes  subdivided 
and  betrays  itself  as  single  symptoms ;  e.  g.,  eyeache,  earache, 
toothache,  neckache,  etc.  So  it  happens  that  the  SAmipathetic 
symi^tom-complex  may  present  the  single  symptom — sneezing — 
or  thin  secretion,  or  the  eye  disturl)ances  Avhich  simulate  a  low 
grade  conjunctivitis  with  asthenopia;  and  a  feAV  times  I  have 
seen  a  red  external  nose  (rosacea)  of  this  origin. 

It  is  not  possible  at  present  to  explain  the  various  nerve 
manifestations  produced  by  inflammation  in  these  parts ;  i.  e., 
why  one  case  suffers  from  the  neuralgic  part  of  the  syndrome 
only  and  why  another  under  the  same  macroscopic  apjiearances 


SYNDROME    OF    NASAL    GANGLION    NEUROSIS  73" 

suffers  only  the  sympatlietic  syndrome.  I  believe  that  others- 
suffer  only  the  motor  or  gustatory  disturliances,  hut  I  am  not 
sufficiently  assured  of  this  to  make  a  positive  statement  to  that 
effect.  The  more  unusual  phenomena  are  even  more  strikingly 
out  the  line  of  inductive  jjliilosophy;  i.e.,  that  injection  of  the- 
nasal  ganglion  should  cure  a  most  pronounced  red  and  enlarged 
external  nose,  a  most  i)ron()unced  vrriter's  cramp,  a  most  pro- 
nounced blepharospasm,  a  most  obstinate,  recurrent  superficial 
corneal  ulceration;  and  equally  striking  has  been  the  almost 
kaleidoscopic  change — betterment  of  some  of  the  severest  dis- 
orders of  the  uveal  tract  immediately  following  full  anaesthesia 
of  the  nasal  ganglion.  That  the  severest  pain  of  photophobia, 
glaucoma,  iritis,  corneal  ulcers,  phlyctenular  keratitis,  inter- 
stitial keratitis — may  be  stopped  by  anaesthesia  of  the  nasal 
ganglion,  frequently  with  immediate  betterment,  is  to  me  also 
at  once  striking  and  strange.  According  to  present  thought, 
the  only  explanation  for  this  is  that  it  is  the  sympathetic  by 
way  of  the  nasal  ganglion  that  conveys  tlie  pain  sense  to  the 
occiput  and  neck,  from  these  lesions,  and  that  it  is  a  nerve 
blocking  at  this  point.  To  stop  pain,  influences  the  lesion  for 
better.  The  fact  that  the  pain  of  glaucoma  could  be  stopped 
by  anaesthetizing  the  nasal  ganglion  was  discovered  by  A.  E. 
Ewing.'"  H.  Ed.  Miller'*  and  W.  H.  Luedde*"  proved  that  in- 
jection of  the  ganglion  lowered  the  intra-ocular  tension  of  glau- 
coma, and  that  the  effect  was  transitory.  I  have  verified  this. 
The  course  of  glaucoma  may  or  may  not  be  influenced  by  treat- 
ment of  the  nasal  ganglion.  Xo  clear  statement  can  be  made 
on  this  iDoint  at  present. 

It  is  genei'ally  admitted  that  the  functions  of  the  sympa- 
thetic nervous  system  among  others,  are  vasomotor  and  secre- 
tory. Sensory  attributes  have  also  been  proved  for  it.  Ana- 
tomically the  fi])res  of  the  cervical  sympatlietic  from  the  nasal 
ganglion  pass  do^^^Iward  by  way  of  the  Vidian  and  carotid 
plexus  to  the  cervical  sympathetic  and  give  branches  to  the 
cervical  nerves  and  proceed  finally  to  the  lower  cervical  gang- 
lion which  is  in  intimate  connection  and  often  fused,  with  the 
first  thoracic.  These  ganglia  are  anatomically  in  association 
Avith,  or  allied  to,  the  nerves  which  in  addition  to  supplying  the 
neck,  also  make  up  the  brachial  plexus,  and  supply  the  upper 


74  HEADACHES    A]S""D    EYE    DISORDERS    OF    ^^ASAL    ORIGIN 

•extremity.     Accelerator  fibres   for   tlie  heart   and    vasomotor 
iibres  for  tiie  lung  also  pass  through  tliese  ganglia. 

The  anatomical  and  physiological  problems  of  the  auto- 
nomic nerves  (sympathetic)  are  very  complex,  and  a  clinician 
may  well  hesitate  approaching  them;  but  it  would  seem  that  the 
Ivnowledge  of  the  present  on  this  subject  permits  the  thought 
that  it  is  a  lesion  of  the  sympathetic  elements  of  the  nasal  gan- 
glion that  explains  not  only  these  vasomotor  secretory  phenom- 
ena, but  also  the  X3ain  referred  into  the  neck,  shoulders,  arm, 
etc.,  the  Vidian  neuralgia;  and  that  these  referred  pains  prob- 
ably come  to  pass  by  virtue  of  the  sympathetic  fibres  which  ar- 
horize  about  cells  (Thane,  Van  Gehuchten,  Dogiel,  Retziens)  in 
the  spinal  ganglia  of  the  nerves  which  make,  eventually,  the 
supply  of  the  neck  and  upper  extremity.  Also,  the  thought 
arises  that  it  is  the  anatomical  connection  of  accelerator  fibres 
for  the  heart  and  vasomotor  fibres  for  the  lungs  with  the  gan- 
glia through  which  the  cervical  sympathetic  passes  (lower  cer- 
vical and  first  thoracic)  that  explains  some  of  the  cases  of 
asthma  of  nasal  origin ;  and  that  the  path  of  the  impulses  is 
from  the  nasal  ganglion  through  A^idian,  upper,  middle  and 
lower  cervical  and  first  thoracic  ganglia,  through  the  last  two 
-of  which  pass  the  heart  and  lung  fibres. 

Much  more  physiologic  fact  is  needed  before  such  conclu- 
sions can  be  asserted. 

I  have  been  unable  to  find  any  statement  of  what  influence 
is  exerted  over  nerve  fibres  in  their  passage  through  a  ganglion 
with  whose  cells  they  have  no  other  relation.  Moreover,  the 
question  may  arise  whether  such  a  state  of  things  exists  phys- 
iologically or  anatomically ;  i.  e.,  Avhether  there  is  not  always 
■some  connection  when  the  fibres  pass  through  a  ganglion.  Some 
influence  must  be  assumed  to  exist  for  the  above  hypothesis.  It 
would  also  appear  to  a  clinician  to  exist. 

If  the  cells  of  the  nasal  ganglion  are  as  resistant  as  those 
of  the  semilunar  ganglion,  it  explains  how  they  may  for  some 
time  resist  in  an  inflamed  environment ;  but  Avhen  once  attacked 
they  may  in  the  same  manner  resist  treatment.  So  it  might  be 
explained  that  intractable  Vidian  neuralgia  is  not  unrelated  to 
the  intractable  vasomotor-secretory  phenomena,   inasmuch   as 


SYXDROME    OF    N^ASAL    GAK^GLION    NEUROSIS  75 

they  are  often  associated  and  are  alike  resistant  to  treatment. 
In  this  connection  it  shonld  be  recalled  that  the  vasomotor- 
secretory  ^Dhenomena  of  the  nose  may  be  excited  (1)  from  the 
nerve-endings;  (2)  the  neuralgia  and  sijm.pathefic  symptoms 
from  the  nasal  fianglion,  or  (3)  the  Vidian  nerve  trunk  within 
the  floor  of  the  sphenoidal  sinus.  In  the  first  instance  the  trunk 
injection  of  Otto  J.  Stein^^  succeeds ;  in  the  second  instance  the 
ganglion  injection  may  succeed,  or  need  repeating;  in  the  third 
instance  the  disorder  must  be  attacked  from  witliin  the  sinus, 
when  it  may  succeed  in  even  the  worst  cases. 

Buch"  made  the  observation  that  tlie  sympathetic  in  health 
was  not  speciall}^  sensitive,  Init  that  it  becomes  very  sensitive 
if  the  animal  be  worried  or  the  nerve  l)ecome  congested.  These 
facts  readily  explain  how  these  cases  may  relapse  from  fatigue, 
anxiety,  apprehension,  friglit,  anger,  or  slight  systemic  toxe- 
mias, inasmuch  as  the  environment  of  the  ganglion  and  nerve 
tissues  may  remain  slightly  inflamed  for  almost  any  length  of 
time,  and  pass  under  the  generic  term  "catarrh." 

I  haA^e  stated  that  I  thought  that  the  control  of  glaucoma 
j)ain  from  the  nasal  ganglion  was  a  nerve  l)locking,  and  I  believe 
that  this  is  true  with  the  control  of  the  other  eye  pains  men- 
tioned above.  The  thought  now  arises  that  it  is  the  sympathetic 
which  runs  through  the  nasal  ganglion  to  the  Vidian,  etc.,  that 
transmits  the  pain  posteriorly  in  many  of  the  painful  eye 
troubles. 

Therapeutically,  it  has  seemed  advantageous  to  stop  the 
pain  and  photophobia  of  some  of  the  eye  diseases  at  the  nasal 
ganglion,  not  for  the  comfort  of  the  patient  only,  but  also  be- 
cause some  cases  have  been  turned  thereby  in  their  course  for 
immediate  improvement  of  what  had  been  a  more  or  less  stub- 
l3orn  condition  (iritis,  glaucoma,  corneal  ulcer,  interstitial 
keratitis,  conjunctivitis),  which  may  argue  possibly  a  trophic 
influence. 

Cauterization  of  the  membrane  over  the  nasal  ganglion 
(acetic  acid)  has  in  some  instances  prolonged  the  helpful  influ- 
>ence;  and  some  were  injected  with  phenol  alcohol. 

In  one  patient  suffering  severe  photoplioliia  Avith  severe 


76  HEADACHES    AND    EYE    DISORDERS    OF    iN^ASAL    ORIGIN 

pain  in  the  lower  half  of  the  head  and  neck  from  a  traumatic 
ulcer  of  the  cornea,  full  cocainization  of  the  ganglion  stopped 
the  photophohia  and  lower-lialf  headache  completely,  and  left 
only  the  sense  of  irritation  produced  hy  the  cinder  upon  its  ar- 
rival on  the  cornea,  which  was  slight.  The  sense  of  first  irri- 
tation remained,  carried  hy  the  ophthalmic  nerve,  and  the 
"deep  and  heavy  pain"  passed  through  the  nasal  ganglion  and 
was  stopped  at  that  point. 

Close  scrutiny  is  required  to  separate  some  of  the  eye  dis- 
turbances which  are  referred  from  the  ganglion,  from  some  eye 
diseases  proper. 

In  several  pronounced  cases  of  asthma  which  remained 
after  the  hay  fever  season,  cocainization  of  the  ganglion 
stopped  the  dyspnea;  and  it  did  not  return. 

In  four  other  cases  secondary  to  post-etlimoidal  sphe- 
noidal inflammation  in  mid-Avinter,  of  greater  or  lesser  sever- 
ity, cocainization  of  the  ganglion  of  one  side  either  stopped 
or  greatly  lessened  the  sibilant  rales  in  the  lung  of  that  side, 
and  relieved  the  sense  of  oppression  on  that  side;  and  in  one 
case  of  right-sided  sphenoidal  empyema,  the  rales  and  sense 
of  oppression  were  on  that  side  only,  and  were  stopped  by  co- 
cainization of  the  ganglion. 

I  believe  now  that  it  is  irritation  of  the  sympathetic  fibres 
at  the  nasal  ganglion  that  explains  the  dilatation  of  one  pupil 
at  the  time  of  coryza,  rather  than  blunting  of  the  third  nerve 
function,  as  I  previously  tliouglit. 

The  argument  outlined  above  seems  to  me  applicable  in 
the  explanation  of  pain  of  cardiac  origin  (angina  pectoris)  be- 
ing referred  into  the  arm;  i.e.,  originating  in  the  heart,  the 
impulse  passes  by  the  sympathetic  upward  to  the  lower  cer- 
vical and  first  thoracic  ganglia,  and  then  to  the  spinal  ganglia 
of  some  of  the  nerves  of  the  brachial  plexus. 

Cocainization  of  the  nasal  ganglion  in  four  cases  of  au- 
tumnal hay  fever  stopped  the  lacrimation  and  burning  or 
itching  eyes.  The  effect  was  permanent  in  one  case,  and  lasted 
one  to  seven  days  in  the  others,  (In  these  ol)servations  I  had 
the  assistance  of  H.  E.  Miller  and  C.  A.  Gundelach.) 

Rhinorrhea  and  sneezing  Avitli  frequent  coryzas,  with 
asthma  and  fever,  but  Avith  little  or  no  headache  are  seen  in 


SYXDROME    OF    XASAL    GAX(;LI0X    NEUROSIS  77 

eliildreii,  as  concomitant  of  post-etlimoidal-splicnoidal  inflam- 
mations and,  I  believe,  are  another  phase  of  the  picture  de- 
scribed above. 

It  seems  to  me  that,  clinically,  there  are  several  types  of 
coryza,  and  among  these  I  am  disposed  to  class  rose  colds, 
hay  fever  and  horse,  etc.,  fevers  produced,  probably,  by  as  many 
varieties  of  causative  ag-ents;  and  that  tlieir  actions  are  se- 
lective, one  or  more  being  peculiar  in  that  they  attack  the  s^^n- 
pathetic  nerve  elements  in  the  nose  and,  furthermore,  the  vas- 
omotor secretory  elements  often  totally  independent  of  the 
pain-prodlicing  elements  of  the  sympathetic. 

"We  have  frequently  seen  the  coryza  manifest  by  dryness 
without  nasal  oljstruction,  which  suggests  paralysis  of  secre- 
tion. Bacterial  cultures  made  ))y  clinicians,  from  the  nose,  at 
the  present  time,  fail  to  differentiate  these  cases. 

These  differences  may  be  explicable  along  the  lines  of 
sensitization  (as  these  ideas  uoav  stand) :  i.  e.,  that  everyone 
is  probably  sensitized  to  or  for  some  extraneous  agent  which 
is  then  for  him  pernicious. 

As  is  well  known,  some  indi\'iduals  are  sensitized  to  or  for 
^g^  albumen,  others  for  strawberry,  others  for  apple,  etc. ; 
others  for  horse  serum,  others  for  the  pollen  of  some  grasses, 
others  for  golclen-rod  and  ragweed.  The  last  three  classes  are 
those  who  develop  horse  asthma  and  spring  and  fall  hay  fever. 

J.  L.  Gooclale's  text-^  in  1914  records  his  observations  (with 
case  reports),  which  seem  to  me  to  promise  a  better  under- 
standing of  the  above-enumerated  problems. 

W.  H.  Haskin-"  read  a  text  to  the  American  Laryngological, 
Rhinological  and  Otological  Society,  1913,  and  showed  a  most 
exquisite  dissection,  in  which  attention  was  called  (with  dem- 
onstration) to  the  widespread  anatomical  connections  of,  and 
the  recognized  physiological  phenomena  connected  Avith  the 
sympathetic. 

H.  H.  ]\Iartin*^  has  had  success  in  the  treatment  of  these 
neuralgic  cases  by  injection  of  the  ganglion. 

I  suggest  for  those  interested  in  these  phenomena  a  peru- 
sal of  Langley's  test"  on  the  SAiupathetic  nervous  system  in 
Schaefer's  Text  Booh  of  Fhysiologij. 


78  HEADACHES    AXD    EYE    DISORDEES    OF    NASAL    ORIGIN 

DIAGNOSIS 

The  diagnosis  of  nasal  ganglion  nonralgia  has  called  into 
consideration  phenomena  that  heretofore  have  been  inexpli- 
cable, an  understanding  of  which  T  think  I  noAv  have. 

The  above-mentioned  syndrome  may  be  produced  by  lesions 
of  the  nerve-trunks  which  supply  the  ganglion,  namely,  the  max- 
illary and  the  Vidian  nerves.  It  is  supplied  with  sensory  fibres 
by  the  maxillary.  The  Vidian  is  composed  of  the  great  su- 
perficial and  the  great  deep  petrosals.  The  great  superficial 
petrosal  comes  from  the  geniculate  ganglion,  bearing  motor 
fibres  from  the  seventh  and  taste  fibres  which  have  arisen  in 
the  anterior  two-thirds  of  the  tongue  and  are  to  reach  the  brain 
by  the  fifth  nerve;  tlie  great  deep  petrosal  is  a  sympathetic 
nerve,  branch  of  the  carotid  plexus.  Both  the  maxillary  and 
the  Vidian  trunks  (Figs.  63  and  66)  frequently  lie  in  very  close 
association  with  the  sphenoid  sinus.  They  may  be  separated 
from  the  cavity  in  tJie  body  of  the  sphenoid  by  only  an  eggshell 
thickness  of  bone;  and  this  may  be  a  fact  as  early  as  the  third 
year  of  life  for  the  second  division  of  the  fifth,  and  the  seventh 
year  for  the  Vidian.  Each  year  of  life  presents  the  same  pos- 
sibilities, from  childhood  to  maturity.  I  learned  this  from  a 
recent  inspection  of  the  matchless  material,  property  of  Warren 
B.  Davis, ^^  Keen  Research  Fellow  of  the  Jefferson  Medical  Col- 
lege, Philadelphia,  and  piiblished^^''  it  Avith  his  consent.  This 
material  consists  of  145  sections  of  the  Caucasian  head  from 
two  months  fetal  life  to  maturity  (twenty-five  years)  uninter- 
rupted, several  specimens  for  each  year  (except  the  eleventh — 
only  one)  showing  the  changes  of  each  year.  Therefore,  when 
inflammation  exists  in  the  cavity  which  occupies  the  body  of 
the  sphenoid  (the  sphenoidal  sinus  or  a  post-ethmoidal  cell) 
it  may  readily  involve  the  associated  nerve-trunks,  either  by 
its  extension,  or  by  its  toxin  passing  through  the  thin  sep- 
arating l)ony  wall.  In  1912  I'^  found  in  some  patients  that 
cocaine  r(^adily  passed  through  this  wall  and  paralyzed  one 
or  sometimes  all  the  branches  of  the  fifth  nerve.  A  lesion  in- 
volving the  nerve-trunks  central  to  the  point  of  union  of  these 
trunks  can  reproduce  or  simulate  the  syndrome  arising  from 
a  lesion  of  such  a  point  of  union.     There  exist,  however,  at 


SYXDKOME    OF    NASAL    GANGLIOX    XEUROSIS  79' 

this  point  of  union,  ganglion  cells.  It  is  not  a  mere  coalition 
of  fi])res.  What  part  clinicall}',  these  multipolar  cells  may 
play,  is  as  yet  unknown ;  but  the  clinical  fact  remains  that  cer- 
tain sphenoidal  inflammatory  cases  simnlate  completely  the 
typical  neuralgic  and  sympathetic  phenomena  arising  in  the 
nasal  ganglion. 

The  differential  diaf/uosis  may  be  made  by  the  following 
facts : 

1.  Cocainization  of  the  nasal  ganglion  stops  the  pain  of 
a  lesion  in  the  ganglion  proper. 

2.  Cocainization  of  the  nasal  ganglion  does  not  in  any  de- 
gree stop  the  pain  created  by  the  more  central  lesion  of  the 
nerve-trunks,  maxillary  and  Vidian,  secondary-  to  sphenoidal 
inflanunation.  These  points  had,  as  a  rule,  lietter  be  proved  on 
several  occasions  before  injection  is  clone.  /  believe  these 
points  have  been  overlooked  or  neglected  by  some  surgeons  tvJio 
have  complained  that  their  results  i.vere  not  as  good  as  mine. 

3.  On  the  other  hand,  intrasphenoidal  application  of 
pain-i'educing  remedies,  such  as  cocaine,  will  under  these  con- 
ditions stop  the  pain — that  is,  a  local  anaesthetic  ai)plied  cen- 
tral to  the  ganglion  is  effective. 

In  addition  to  these  x^oi^fs  of  difference,  there  is  often 
a  congestion  and  thickening  (hyperplastic  post-ethmoiditis)  at 
the  site  of  the  sphenopalatine  foramen  when  the  nasal  gan- 
glion is  the  starting  point  for  the  neuralgia.  This  is  more  par- 
ticularly true  for  the  cases  of  inflammatory  origin,  which  are 
the  usual  cases. 

PROGNOSIS 

The  prognosis  of  nasal  ganglion  neuralgia  is  beset  by 
several  perplexities  on  which  I  have  speculated.  Frequently 
in  severe  cases  that  had  been  relieved  by  injection  of  alcohol, 
the  benefit  proved  so  transitory  as  to  arouse  the  inquiry :  Was 
it  Avorth  while?  In  contrast  with  these,  hoAvever,  are  others 
of  high  grade  Avhich  Avere  easily  cured  by  simple  applications 
of  cocaine,  formaldehyde,  or  silver  to  the  inflamed  sphenopal- 
atine foramen  district.  Possibly  all  such  A^ariations  could  be 
satisfactorily  explained  Avere  post-mortem  material  as  fre- 
quently available  in  these  cases  as  is  the  diseased  lung  or  liver 


.'80  HEADACHES    AND    EYE    DISOEDERS    OF    NASAL    ORIGIN 

or  heart.  Possibly  an  exact  knoAvledge  of  the  anatomy  of  the 
ganglion  in  man  (whieli  is  not  known)  wonld  1)e  helpful  also. 
I  feel,  however,  that  I  have  a  better  understanding  of  some  of 
these  points  now,  from  further  clinical  experience  and  a  knowl- 
edge of  work  on  collateral  lines  by  May,^^  of  London,  although 
animal  experiment,  or  post-mort^n  observation  of  my  own  is 
still  wanting.  The  best  treatises  on  anatomy  give  only  a  few 
Avords  of  description  to  its  histology.  The  gray  matter  of  the 
ganglion  does  not  involve  all  of  the  sphenopalatine  branches 
of  the  maxillary  nerve,  liut  is  placed  at  the  back  part  at  the 
point  of  juncture  of  the  Vidian  nerve,  so  that  many  if  not  all 
of  the  fibres  of  tlie  sphenopalatine  nerves  proceeding  to  the  nose 
and  palate  pass  to  their  destination  without  being  incorporated 
Avitli  the  ganglion  mass. 

The  fact  that  herpes  has  never  been  seen  as  a  part  of  this 
syndrome  would  seem  to  bear  out  this  point,  for  herpes  is 
never  produced  by  lesions  of  the  sensory  nerve  trunks ;  l)ut  only 
b)}^  lesions  of  the  sensory  cells.  The  ganglion  cells,  therefore, 
would  seem  to  be  a  part  of  its  s^anpathetic  attributes,  which 
are  constituted  by  the  Vidian  nerve.  It  seems  true  from  clin- 
ical experience,  however,  that  the  Vidian  nerve  carries  fibres 
which  transmit  the  sense  of  pain  also.  Certain  noses  have  been 
propitious  for  cocainization  of  the  tissues  internal  to  the  as- 
sumed position  of  the  ganglion  with  the  effect  of  stopping  en- 
tirely the  pain  of  posterior  distrilnition ;  and  then,  when  the 
applicator  was  placed  external  to  the  assumed  position  of  the 
ganglion  the  pain  of  anterior  distrilnition  stopped.  When 
placed  in  the  center,  it  would  stop  both  anterior  and  posterior 
pains.  In  other  Avords,  it  would  seem  that  the  trunks  of  the 
nerves  supplying  the  ganglion  in  these  cases  could  be  cocainized 
separately.  This  has  seemed  true  also  for  injection  and  elec- 
trical (faradic)  stimulation.  Alcohol  injected  on  the  Vidian 
side  of  the  ganglion  lias  produced  great  pain  of  posterior  dis- 
tribution ;  injected  on  the  side  of  the  second  division  of  the 
fifth  it  made  the  anterior  pain.  The  needle  in  these  positions 
was  attached  to  the  faradic  current,  the  other  j)ole  in  the  hand, 
with  the  same  results. 

The  recent  w^ork  of  Dr.  Otto  May,^^  seems  to  me  to  explain 
rsome   of  the  transitory  results   of  injection.     He   proved  ex- 


SYNDROME    OF    NASAL    GANCxLION    NEUROSIS  81 

perimentally  that  the  cells  of  the  Gasserian  ganglion  in  the 
goat,  cat  and  clog  are  not  at  all  readily  destroyed  by  alcohol; 
that  they  are  qnite  resistant  to  its  action  even  though  the  gan- 
glion Avere  surgically  exposed  and  the  injection  put  directly  into 
its  substance.  He  also  proved  that  the  nerve-fibres  are  much 
more  Aoilnerable  to  alcohol  than  the  cells ;  but  that  the  injec- 
tion must  be  made  exactly  into  the  nerve-trunk,  "When  the  al- 
cohol was  put  merely  around  the  nerve,  its  effect,  although 
marked,  was  transitory — the  nerve  quickly  recovered  its  func- 
tion. Lannois  and  Berial"  have  proved  the  anatomical  effect 
of  the  clinical  injection  of  alcohol  into  the  nerve-trunks  is  very 
slight. 

So  it  would  seem  that  inasmuch  as  the  ganglion  is  small 
(5  mm.)  and  difficult  of  access,  we  may  assume  that  the  trans- 
itory results  have  followed  the  instillation  of  alcohol  into  its 
environment  rather  than  into  its  substance ;  and  that  the  highly 
satisfactory  results  have  followed  the  exact  instillation  of  the 
alcohol  into  its  midst,  or  into  the  trunks  supplying  it ;  and 
that  the  results  may  not  be  permanent  even  under  tliese  cir- 
cumstances, because  these  tissues  are  so  difficult  of  destruction. 
(Whatever  made  the  pain  in  the  original  cell,  one  may  sup- 
pose, may  make  it  in  the  regenerated  cell.)  The  clinical  value 
of  the  injection,  however,  must  be  admitted.  And,  on  the  other 
hand,  the  severe  cases  from  which  the  patients  have  recovered 
so  satisfactorily  from  surface  applications  to  the  membrane 
covering  the  sphenopalatine  foramen,  and  its  immediate  sur- 
rounding (whereby  an  inflammation  was  allayed),  we  may  as- 
sume to  have  been  produced  by  irritants  to  the  cells  and  fibres 
without  their  actual  structural  involvement,  their  power  of  re- 
sistance being  great,  as  shown  by  Dr.  May.  In  this  I  am  as- 
suming these  cells  and  fibres  to  be  alike  with  those  observed 
by  Dr.  May.  These  assumptions  may  likewise  explain  why  the 
complete  clinical  picture  has  so  seldom  been  observed  in  a  sin- 
gle case.  The  complete  picture  would  recpire  the  complete  in- 
volvement of  all  the  cells  and  fibres  of  the  ganglion  alike,  which 
in  accordance  with  the  above  assumption  would  not  be  apt  to 
happen. 

The  nasal  ganglion  neuralgia  that  recurs  at  long  intervals 
secondary  to  a   suppurative  post-ethmoiditis  I  believe  is   ex- 


8_J  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

plained  by  the  fact  that  a  pad  of  about  0.5  cm.  lies  between  the 
post-ethmoidal  or  upper  anterior  wall  of  the  sphenomaxillary 
fossa  and  the  nasal  ganglion.  The  establishment  of  the  pain 
at  long  intervals  (3  to  12  months)  has  been,  almost  nniformly, 
by  a  coryza  recognizable  in  this  district.  I  translate  this  as  a 
condition  which  gives  freedom  from  pain  in  times  when  there 
is  no  acnte  inflammation,  by  virtue  of  the  thick  pad  which 
separates  the  ganglion  from  the  inflamed  cells.  At  the  time 
of  an  acute  inflammation  in  the  cells  enough  toxins  are  made 
to  spread  through  the  pad  and  affect  the  ganglion.  I  have  seen 
this  form  a  number  of  times  make  the  picture  of  a  complete 
ophthalmic  migraine,  recurrent  at  3  to  18  months'  intervals. 
A  nasal  ganglion  neuralgia  that  arises  secondary  to  a 
hyperplastic  post-ethmoidal  sphenoiditis,  without  pus,  is  very 
much  more  apt  to  recur  at  much  shorter  intervals  if  indeed  it 
be  not  more  or  less  present  constantly.  There  is  no  separat- 
ing pad  between  the  anterior  face  of  the  sphenoid  and  the  gan- 
glion. Only  a  small  amount  of  connective  tissue  is  present  here. 
The  inflamniatory  process  or  its  toxins  have  only  a  small  sepa- 
ration to  traverse  to  reach  the  ganglion. 

TREATMENT 

In  the  treatment  of  these  cases  various  remedies  and  sev- 
eral surgical  means  have  been  employed.  Applications  Avere 
made  to  the  region  of  the  sphenopalatine  foramen  of  2  per 
cent  solution  of  silver  nitrate,  0.4  per  cent  solution  gaseous  for- 
maldehyde, 0.5  per  cent  phenol  with  0.1  per  cent  iodine  as  a 
wash.  In  the  more  severe  and  stubborn  cases  injections  of 
phenol  alcohol  were  used  and  in  the  worst,  the  patients  were 
operated  on  (intranasally)  with  the  intention  of  removing  the 
ganglion.  But  treatment  has  heretofore  had  only  passing  men- 
tion.   I  feel  that  it  should  be  taken  up  here  in  detail. 

Anatomic  Considerations 

The  treatment  of  these  neuralgias  has  always  been  beset 
by  difficulties  Avhich  are  occasioned  by  the  anatomy  of  these 
parts.  The  simple  painting  of  the  region  of  the  sphenopalatine 
foramen  will  often  be  found  difficult  because  of  an  irregularity^ 
on  the  septum,  or  the  configuration  of  the  lower  turbinate,  or 


SYNDROME    OF    :N^ASAL    GANGLIOX    NEUROSIS 


83 


both.  Certainly,  in  a  nose  Avliieli  presents  a  straight  septum, 
a  wide  caliber  nasal  fossa,  and  a  straight  loAver  turbinate  there 
can  be  no  difficulty  in  reaching  accurately  the  region  of  the 
sphenopalatine  foramen.  In  such  a  nose,  a  needle  bent  at  a 
right  angle  0.5  or  0.66  cm.  from  its  end  could  be  introduced 
along  the  septum,  to  a  point  0.33  cm.  posterior  to  and  slightly 


Fig.   42. — Showing  pterygoid   process   /   projecting   forward  beyond  the   posterior   limit   of   spheno- 
palatine  foramen. 

above  the  posterior  tip  of  the  middle  turl)inate ;  and  could  then 
be  turned  to  point  outward  Avhich  would  l)ring  its  point  to  the 
membrane  covering  the  sphenopalatine  foramen.  This  could 
readily  be  punctured,  thereby  bringing  the  needle's  point  di- 
rectly into  the  sphenomaxillary  fossa  at  the  site  of  the  nasal 
ganglion. 


84  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

This  would  seemingly  be  the  simplest  and  best  method  of 
injecting-  medicaments  into  the  ganglion.  Bnt  even  were  this 
always  a  possible  technique,  it  would  still  fail  at  times  because 
the  sphenopalatine  foramen  is  sometimes  placed  posterior  to 
the  anterior  surface  of  the  pterygoid  process  (Fig,  42)  opening 
as  it  were  into  the  Vidian  canal  rather  than  the  sphenomaxillary 
fossa.     (Compare  Fig.  43.)     Such  a  pterygoid  process  is  V- 


Fig.   43. — Showing  usual   sphenopalatine  foramen.     The  pterygoid  process   is  behind   it. 

shaped,  apex  forward.  Injection  under  these  conditions  would 
be  into  the  Vidian  nerve  and  not  into  the  ganglion.  It  is  for 
these  reasons  that  I  should  like  to  call  attention  to  the  method 
of  injection  by  means  of  the  straight  needle,  which  may  be 
done  in  practically  all  noses,  however  irregular  or  narrow,  and, 
under  control,  is  almost  infallible  in  its  accuracy.  The  con- 
trol consists  in  measurement  of  how  far  back  of  the  posterior 
tip  of  the  middle  turbinate  the  ganglion  lies,  irrelevant  to  the 


SYNDROME    OF    NASAL    GANGLION    NEUROSIS  85 

pteryg-oid  process.  The  splienomaxillary  fossa  is  constantly 
reached  about  at  its  center,  0.33  cm.  back  of  the  posterior  tip 
of  middle  turbinate;  and  it  is  this  fact  that  I  utilize  in  the 
therapeutic  injection.  Should  the  surgeon  rely  on  the  but- 
tress of  a  solid  pterygoid  process  to  stop  his  needle  when  it  is 
being  pushed  l)ackward,  as  might  seem  perfectly  feasible  under 
the  rule  of  the  anatomy  of  the  pterygoid  process,  he  will  find 
himself  disappointed  frequently  because  the  pterygoid  proc- 
ess is  hollowed  out  by  a  prolongation  of  the  sphenoidal  sinus 
downward  into  it  as  far  as  the  bifurcation  of  the  plates.     The 


Fig.   44. — Showing    correct    placing    of    ihe    needle.       (After    Loeb.) 

needle  then  crosses  the  sphenomaxillary  fossa  and  penetrates 
a  thin  iilm  of  bone  to  enter  the  sphenoidal  sinus  to  meet  witli 
firm  resistance  only  in  the  posterior  wall  of  the  sinus,  or  pos- 
sil)ly  not  even  there.  It  might  readily  enter  the  cranial  cav- 
ity. The  injection  will  then  l^e  into  the  sphenoidal  sinus  or 
cranial  cavity.  Then  too,  the  sphenoidal  sinus  is  somethnes  set 
so  far  down  in  the  body  of  the  sphenoid  that  its  lower  aspect  lies 
below  the  line  of  the  needle  thrust.  (Fig.  4G.)  Tnder  these 
settings  the  needle  enters  the  main  cavity  of  the  sphenoid  as 
soon  as  it  crosses  tlie  sphenomaxillary  fossa. 

The  relation   of   the   spheno])alatine   foramen   to   the   pos- 


8G 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


terior  tip  of  tlie  middle  turbinate  is  one  of  the  most  constant 
in  the  nose.  Even  though  tlie  anterior  aspect  of  the  pterygoid 
process  be  V-shaped  and  be  relatively  forward  of  the  opening 
sphenopalatine  foramen  it  disturbs  this  relation  little  or  none. 
The  posterior  tip  of  tlie  middle  turbinate  always  marks  the 
anterior  limit  of  the  sphenopalatine  foramen.  The  spheno- 
maxillary fossa  must,  of  course,  needs  lie  lateral  to  the  plane 
of  the  sphenopalatine  foramen.  These  relations  being  borne 
in  mind,  it  must  appear  that  a  straight  needle  introduced  into 


Fig.   45. — Showing    both    straight    and    curved    needles    (/-.?)    correctly    placed. 

Record  syringe. 


S.   A    satisfactory 


the  nose  from  the  nostril  to  pass  under  the  posterior  tip  of 
the  middle  turbinate  at  its  origin  from  the  lateral  wall,  in  a 
direction  backward  and  upward  and  slightly  outward,  must 
pass  out  of  the  nasal  fossa  into  the  sphenomaxillary  fossa  and 
enter  the  nasal  ganglion  or  its  immediate  vicinity.  The  dis- 
tance from  the  point  of  entrance  of  the  needle  so  placed  and 
ganglion  tissue  is  almost  invariably  0.66  cm. 

The  lateral  wall  of  the  nose  plays  an  important  part  in 
this  technique  and  its  variations  should  be  borne  in  mind, 
to  wit : 


SYXDROME    OF    XASAL    GAXGLIOX    XEUROSTS 


87 


1.  In  the  middle  meatus  the  lateral  Avail  sometimes  extends 
abrnpth"  outward  and  slightly  forward,  from  the  jDosterior  tip 
of  the  middle  turbinate,  even  to  such  a  degree  that  it  forms  the 
anterior  limit  of  the  sphenomaxillary  fossa,  excluding  the  pos- 
terior wall  of  the  maxillary  antrum  from  participation  in  these 
boundaries.  When  this  is  true,  a  very  careful  estimate  must 
be  made  of  the  origin  of  the  middle  turliinate  at  its  posterior 


Fig.  46. — Showing  nasal  ganglion  needle  having  passed  across  the  sphenomaxillary  fossa 
and  then  through  the  thin  wall  of  a  low  set  sphenoidal  sinus.  (In  this  picture  the  needle  is 
shown  at  a  point  slightly  forward  of  the  correct  point  for  the  injection  of  the  gangljon  in  order 
to   e.xaggerate   the   error.) 

tip,  because  such  a  pouching  outward  (concavity)  of  the  lateral 
wall  permits  the  tip  of  the  iieedle  to  be  placed  as  far  outward 
(lateral)  as  the  line  of  the  foramen  rotundum.  Pushed  back- 
ward under  these  circumstances,  the  needle  would  reach  a 
point  lateral  to  the  ganglion.  Such  a  wall  is,  however,  not  dif- 
ficult to  estimate  and  is  readily  punctured,  usually  because  the 
needle  approaches  it  at  almost  a  right  angle. 

2.  The  lateral  wall  in  the  middle  meatus  is  sometimes 
straight  and  smooth  and  of  very  hard  bone.     The  point  of  the 


88  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

needle  placed  under  the  tip  of  the  turbinate  attached  to  such 
a  wall  may  often  be  pushed  backward  without  penetrating  the 
wall.  The  tip  of  the  turbinate  will  be  punctured  and  the  point 
of  the  needle  pass  submucous  backward  and  upward  to  slip 
into  the  opening  of  the  sphenopalatine  foramen  and  if  carried 
farther  backward  will  enter  the  Vidian  canal,  Avhich  is  on  a 
line  internal  to  the  ganglion.  This  wall  indeed  may  be  so 
straight,  hard  and  smooth  as  to  defy  all  attempts  to  pierce  it 


Fig.   47. — Showing  needle  transfixing  the   middle   turbinate.      It   has  been   placed  too   far  forward. 
The   needle  2  shows   the   correct  placing. 


with  a  straight  needle  introduced  from  the  nostril.  It  must 
then  be  cut  away  witli  a  burr,  thereby  making  a  permanent  and 
easy  access  to  the  ganglion;  or  the  curved  needle  passed  around 
the  posterior  tip  of  the  middle  turbinate  through  the  spheno- 
palatine foramen  may  be  better  in  these  cases.  The  practice 
of  cutting  away  the  wall  with  a  burr  is  not  to  be  reconnnended 
as  a  routine  measure  because  the  sphenopalatine  or  descend- 
ing palatine  or  even  the  internal  maxillary  artery  may  be  in- 
jured with  considerable  hemorrhage  which  may  be  difficult  to 


SYNDROME    OF    N^ASAL    GANGLION    NEUROSIS  89" 

control.     These  arteries  are  rarely  injured  by  the  use  of  the 
needle  alone. 

3.  Very  rarely  is  the  lateral  wall  convex. 

4.  The  lateral  wall  in  the  upper  meatus  of  the  nose  is 
nsually  on  a  plane  intei-nal  to  that  of  the  middle  meatus;  hut 
not  always.  It  sometimes  dips  sharply  outward,  leaving  the 
middle  turhinate  a  very  prominently  marked  thin  tilm  of  the 
bone ;  posteriorly,  however,  it  i:)roceeds  inward  finally  to  come  to 
be  on  the  same  plane  as  the  middle  meatus,  one  meatus  above 
and  the  other  below  the  crista  ethmoidalis  as  it  ends  on  the  an- 
terior semi-circle  of  the  sphenopalatine  foramen.  (Compare 
mth  Fig.  47.) 

This  foramen  is  constantly  immediately  posterior  to,  with 
its  center  slightly  above,  the  posterior  limit  of  the  origin  of  the 
middle  turbinate  from  the  crista  ethmoidalis  (Figs.  41  and  43). 
The  crista  ethmoidalis  of  the  perpendicular  plate  of  the  palate 
bone  almost  always  extends  slightly  into  the  sphenopalatine 
foramen,  sul)dividing  its  anterior  semi-cirde  into  an  uppei*  two- 
thirds  or  three-fourths  and  a  lower  third  or  fourth.  There  is 
usually  a  like  marking  on  the  posterior  semi-circle.  In  foi"ty- 
seven  heads  this  rule  Avas  broken  once  when  the  entire  spheno- 
palatine foramen  was  placed  2  mm.  above  the  crista.  The  di- 
ameter of  the  sphenopalatine  foramen  varies;  but  this  seems 
to  make  little  or  no  difference  in  this  technique. 

Instrumentarium 

For  the  injection  of  the  nasal  ganglion  I  use  a  simple 
straight  steel  needle  1  mm.  in  diameter.  This  is  of  consider- 
able strength;  and  fastened  in  a  heavy  crossbar  enables  the 
surgeon  to  secure  it  in  a  strong  grasp  and  put  great  pressure 
on  it.  My  associates,  Drs.  A.  C.  Gundelach,  II.  E.  Miller,  and 
W.  E.  Saner,  have  suggested  (and  employed)  a  needle  with 
a  trocar  and  tiange  or  ring  from  OS)  to  0.(36  cm.  from  its  point 
to  prevent  too  deep  placement  or  insertion.  Familiarity  with 
this  technique  I  believe  will  render  the  flange  unnecessary.  I  al- 
ways have  at  hand  a  curved  tip  needle  also,  because  sometimes 
the  lateral  wall  of  the  nose  is  so  hard  that  it  cannot  be  punc- 
tured by  the  straight  needle.  The  curved  tip  enables  one  to 
curl  around  the  tip  of  the  turlnnate  and  cntci-  the  fossa  tlirough 


DO  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

the  splieiiopalatine  foramen.     It  seems  to  me  a  less  satisfac- 
tory means   of   approaching-   the   ganglion   than   the   straight 
needle. 

Technique 

The  ganglion  is  cocainized  1)y  an  applicator  carrying  one 
drop  saturated  (90%)  watery  solution  cocaine  hydrochlorate 
placed  nnder  the  tip  of  the  middle  tnrl)inate  for  live  minutes. 
It  is  then  moved  to  lie  over  the  sphenopalatine  foramen  just 
posterior  to  the  posterior  tip  of  the  middle  turbinate  and  al- 
lowed to  remain  there  five  minates.  The  combined  application 
under  and  posterior  to  the  tip  of  the  middle  turbinate  is  ten 
minutes,  one  applicator  carrying  the  one  drop  being  moved 
from  one  place  to  the  other.  Injection  under  insufficient  an- 
aesthesia is  very  painful. 

From  the  preceding  description  it  is  evident  that  a  straight 
needle  introduced  through  the  nostril  in  a  direction  backward, 
upward  and  slightly  outward,  approaching  the  lateral  wall  of 
the  nose  at  a  point  in  the  middle  meatus  marked  by  the  origin 
of  the  posterior  tip  of  the  bony  middle  turbinate,  arrives  al- 
most at  once  on  the  anterior  wall  of  the  sphenomaxillary  fossa. 
Should  its  point  now  be  pushed  backward  0.(36  cm.  it  will 
usually  enter  the  sphenopalatine  ganglion  or  its  immediate  vi- 
cinity (Fig.  44).  Experiment  on  the  cadaver  has  proved,  how- 
ever, that  it  is  better  to  enter  the  point  of  the  needle  2  mm.  an- 
terior to  the  posterior  tip  of  the  middle  turbinate.  Pushed  back- 
ward from  this  point  it  proceeds  in  a  direction  slightly  more  up- 
^vard  and  more  outward  than  it  would  from  the  point  farther 
back,  and  thereby  it  strikes  more  accurately  the  region  of  the 
ganglion. 

It  may  appear  that  the  correct  placing  and  insertion  of 
the  needle  is  a  bit  of  technique  of  easy  and  certain  execution.  It 
has  not,  however,  proved  so  in  my  hands.  A  number  of  speci- 
mens operated  on  show  the  possible  failures:  (1)  The  Vidian 
canal  may  be  injected  because  the  lateral  wall  of  the  nose  is 
very  hard  and  smooth.  The  tip  of  the  needle  Avill  not  pene- 
trate it,  but  slides  over  it  to  the  outlet  of  the  A^idian  canal. 
When  it  is  pushed  backward  it  passes  under  the  tip  of  the  mid- 
dle turbinate  and  crosses  the  sphenopalatine  foramen  to  enter 


SYNDROME    OF    NASAL    GANGLION    NEUROSIS 


91 


the  anterior  outlet  of  the  vidian  canal.  A  perfect  application 
to  the  Vidian  nerve  may  then  be  made.  (2)  The  middle  meatus 
wall  may  dip  abruptly  outward  from  the  sphenopalatine  fora- 
men l)efore  it  beginfe  to  extend  forward;  and  the  upper  meatus 
wall  may  be  of  similar  curvature.  In  such  a  nose,  the  needle 
may  of  course  be  placed  correctly  and  arrive  at  the  proper 
point  in  the  sphenopalatine  ganglion.  If,  however,  it  be  placed  a 
little  too  far  behind  and  below,  it  will,  when  pushed  backward, 
pass  under  the  tip  of  the  turbinate  and  cross  the  sphenopala- 


Fig.  48. — Showing  needle  (point)  having  passed  across  the  sphenomaxillary  fossa  4  to 
be  free  in  a  prolongation  of  the  sphenoid  sinus  ^  prolonged  downward  into  the  pterygoid  process. 
/.  The  general  cavity  of  the  sphenoid.  5.  The  nasal  ganglion.  5.  The  needle.  This  drawing  is 
from  a  sagittal  section  just  lateral   to  the  Vidian  canal   seen   from  without. 


tine  foramen,  as  stated  above,  to  enter  the  Vidian  canal.  And 
should  it  be  placed  slightly  too  far  foi'ward  it  will  readily  trans- 
fix the  thin  film  of  bone  representing  the  middle  turbinate.  Its 
point,  when  pushed  0.66  cm.  backward,  will  lie  free  in  the  upper 
meatus  (Fig.  47).  Injection  in  the  first  instance  \d\\  be  into 
the  Vidian  nerve  and  in  the  second  instance  into  the  free  upper 
meatus.  In  the  latter  circumstance,  the  injected  solution  will 
flow  immediately  backward  and  dowmvard  into  tlie  jiharynx, 
assuming  the  operation  to  be  performed  in  the  erect  posture. 


92  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

(3)  A  needle  carried  too  far  back  may  cross  the  sphenomax- 
illary fossa  to  enter  the  cavity  of  the  sphenoid,  which  may  be 
set  rather  low  in  the  body  of  the  sphenoid  (Fig.  46).  (4)  A 
needle  pushed  too  far  liack  may  cross  the  sphenomaxillary 
fossa  to  enter  a  prolongation  of  the  sphenoidal  sinus  down- 
Avard  into  the  pterygoid  process  (Fig.  48). 

The  lower  turbinate  frequently  interferes  with  an  easy 
and  accurate  placing  of  the  needle  point.  This  happens  read- 
ily when  the  turbinate  is  placed  somewhat  higher  rather  than 
lower  on  the  lateral  wall.  Under  such  conditions,  the  tip  of 
the  nose  must  be  raised  well  up  before  a  straight  line  may  pass 
over  the  upper  convexity  of  the  body  of  the  lower  turbinate  to 
reacli  tlie  desired  point  under  the  i)Osterior  tip  of  the  middle 
turbinate;  and  sometimes  even  then,  considerable  downward 
pressure  will  have  to  be  exerted  on  the  lower  turbinate  by  the 


Fig.  49. 

needle  as  it  passes  backward,  in  order  to  permit  it  to  reach 
its  destination. 

Irregularities  on  the  septum  may  interfere  with  the  pass- 
ing of  the  needle  backward.  They  are  apt,  however,  to  be  in- 
dividual for  that  particular  nose.  The  tubercle  of  the  septum 
lies  above  the  line  sought  by  the  needle. 

I  prefer  the  simple  straight  needle  (Fig.  49)  to  be  inserted 
under  slight  or  great  pressure,  as  the  case  may  be.  Under  slight 
pressure  it  is  very  easy  to  measure  0.66  cm.  distance  inser- 
tion ;  but  when  it  requires  great  pressure,  it  is  by  no  means 
easy  to  estimate  this  distance.  For  this  reason  I  prefer  to 
withdraw  the  needle  when  I  think  I  have  gone  the  right  depth. 
While  the  needle  is  out  of  the  nose,  I  determine  that  it  has  not 
been  plugged  with  bone — that  it  is  open — and  reinsert  it  into 
the  opening  from  which  it  has  been  withdrawn.  On  reinsertion 
the  correct  distance  may  he  measured  exactly,  because  it  requires 


SYNDROME    OF    NASAL    GAKGLIOX    NEUROSIS  93 

no  strengtli  or  pressure  to  replace  it.    One-half  c.c.  5  per  cent 
phenol  in  95  per  cent  alcohol  is  then  injected. 

It  is  my  practice  to  rest  the  h^^pothenar  eminence  of  my 
hand  on  the  patient's  chin,  placing  the  other  arm  aronnd  the 
patient's  head  as  soon  as  the  point  is  in  position.  In  this  way 
strong  and  controlled  pressure  may  be  put  on  the  needle.  It 
is  desirable  that  it  should  not  jump  across  the  sphenomaxillary 
fossa,  but  proceed  backward  cautiously.  Should  the  wail  be 
liard  and  straight  and  not  possible  of  penetration  by  pressure 
thus  applied,  the  needle  may  be  taken  firmly  by  the  crossbar 
mentioned  above,  and  thereby  rotated  to  and  fro  through  a 
«emi-circle  from  side  to  side,  using  it  as  a  hand  drill  to  pene- 
trate the  bone.  The  lateral  wall  may  possibly  be  too  hard  to 
be  penetrated  this  way.  Should  the  bone  be  too  hard  to  pene- 
trate by  a  straight  needle,  a  curved- tip  needle  may  be  employed 
curling  from  below  upward  and  outward  just  back  of  the  pos- 
terior tip  of  the  middle  turbinate.  (Fig.  45.)  It  is  usually  not 
difficult  to  pass  through  the  sphenopalatine  foramen  in  this  way. 
E.  M.  Holmes"^  uses  his  nasopharyngoscoi^e  to  direct  the  placing 
•of  the  curved  needle.  A  machine  drill  or  burr  may  be  employed 
(see  above)  to  remove  the  lateral  wall  for  access  to  the  ganglion. 
It  is  not,  hoAvever,  to  be  recommended  as  it  may  injure  the 
large  arteries  found  here. 

I  have  already  spoken  of  applications  of  silver  nitrate  so- 
lution and  formaldehyde  made  to  the  membrane  covering  the 
sphenopalatine  foramen  (which  is  usually  inflamed).  Often 
this  suffices  to  stop  the  pain.  "When  it  does  not,  I  recommend 
that  the  ganglion  be  injected  with  a  5  per  cent  plienol  solution 
in  95  per  cent  alcohol.  Formerly,  I  injected  approximately 
two  or  three  drops  of  this  solution,  and  very  often  it  sufficed; 
but  the  number  of  failures  seemed  to  me  unnecessarily  large. 
For  this  reason,  I  have  gradually  increased  the  amount  of  the 
injection  to  0.5  c.c.  This  larger  amount  is  more  successful, 
possibly  for  the  reason  that  the  ganglion  is  small  and  prol)ably 
frequently  missed,  to  be  influenced  by  the  solution  placed  in  its 
neighborhood.  Alcohol  alone,  as  advocated  by  Schlosser*'*'  in 
1893,  used  in  these  parts  is  intensely  painful.  For  this  reason 
I  have  added  5  per  cent  phenol'*  to  it,  which  renders  it  painless 
in  small  injections — three  or  four  di'ops.     In  0.5  c.c.  amounts 


94  HEADACHES    AND    EYE    DISORDERS    OF    JSTASAL    ORIGIN 

it  is  usually  followed  by  a  slight  sense  of  pain,  Avhieh  the  pa- 
tient recognizes  as  different  from  his  neuralgia,  and  which  lasts 
from  two  hours  to  three  days.  I  have  used  5  per  cent  phenol  in 
water  with  possi])ly  less  satisfactory  results  than  the  alcohol 
comhination.  No  untoAvard  consequences  have  followed  this 
procedure,  except  on  one  occasion*^''  wlien  the  tissues  of  the 
sphenomaxillary  fossa  Avere  evidently  very  loose.  The  alcohol 
passed  outward  and  upward  to  reach  the  abducens  in  the  sphe- 
noidal fissure,  paralyzing  it.  It  recovered  completeh'  in  three 
months.  This  treatment  has  been  highly  satisfactory  in  the 
great  majority  of  cases.  The  injection,  however,  in  old  and 
severe  cases  must  be  repeated,  possibly  as  often  as  ten  times, 
iisuaUy,  lioivever,  not  more  than  three.  Rarely  there  recurs, 
in  severe  cases,  a  considerable  degree  of  pain,  after  from  four 
to  six  weeks  of  comfort.  In  these  cases,  a  rather  strange  plie- 
n,omenon  appears ;  namely,  that  cocaine  applied  to  the  region 
of  the  ganglion  is  at  once  painful,  and  the  deeper  the  cocainiza- 
tion  the  more  so  it  becomes.  And,  on  the  other  hand,  irritants 
such  as  stronger  solutions  of  silver  nitrate  are  soothing.  I 
have  seen  five  cases  of  this  type.  This  phase  Avas  transitory. 
In  old  severe  cases,  I  belioA^e  the  difficulty  of  obtaining  lasting 
relief  is  explained  by  the  fact  that  the  ganglion  is  surrounded 
by  the  changes  of  a  hyperplastic  post-ethmoidal  sphenoiditis. 
In  this  condition  it  is  not  uncommon  to  find  on  opening  the 
cells,  that  they  contain  polyps  Avhere  no  evidence  of  tlieir  pres- 
ence existed  in  the  nose.  Inasmuch  as  the  sphenomaxillary 
fossa  is  so  like  a  paranasal  cell  (page  61),  it  is  most  plausible 
to  assume  that  changes  occur  in  it  as  a  result  of  the  hyper- 
plastic changes  that  surround  it  on  all  sides,  saA^e  the  external 
aspect.  A  ganglion  imbedded  in  this  tissue  of  Ioav  grade  chronic 
inflammation,  it  Avould  seem,  must  be  irritated  by  it.  Injection 
of  this  fossa  Avitli  ph(Miol-alcohol  often  has  tlie  effect  of  reduc- 
ing the  hyperplastic  changes. 

Each  injection  should  be  folloAved  by  some  lessening  of 
the  patient's  suffering.  It  may  be  repeated  as  often  as  needs 
be,  alloAving  an  increasing  span  of  time  betAveen  each,  i.  e.,  the 
second  tAvo  or  three  Aveeks  after  the  first,  the  third  from  four 
to  six  Aveeks  after  the  second,  increasing  the  span  then  to  six 
weeks  each  time.    I  suggest  this,  because  the  reaction  following- 


SYNDROME    OF    NASAL    GANGLION    NEUROSLS  95 

the  instillation  of  the  phenol-alcohol  becomes  more  severe  the 
oftener  it  is  done.  Severe  cases  of  this  class  are  not  only  a 
terrible  affliction  for  the  patient,  hid  tlieii  also  put  tJic  surgeon 
to  Ms  iviVs  end  for  judgment,  perseverance  and  slxiU.  These 
facts  cannot  he  too  greatly  emphasised.  Particularly  difficult 
of  judgment  are  cases  where  anaesthesia  of  the  ganglion  stops 
the  pain,  but  in  which  there  is  in  addition,  a  considerable  hyper- 
plastic sphenoiditis,  in  frail,  nervous  patients.  The  surgeon 
hesitates  to  perform  the  radical  sphenoid  operation  because  of 
the  low  resistance  of  the  patient.  Patient  efforts  l)y  injection 
usually  succeed.  The  shock  of  the  injection  is  very  much  less 
than  the  sphenoid  operation,  but  these  cases  usually  require 
more  perseverance  because  the  sphenoiditis  may  reestablish  the 
pain  by  virtue  of  the  maxillary  and  Vidian  nerves  passing 
through  the  bone  before  reaching  the  ganglion.  This  class  of 
cases  Avill  be  considered  again  with  more  detail  in  the  chapter 
on  Hyperplastic  Sphenoiditis. 


CHAPTER  III 

HYPERPLASTIC    SPHENOIDITIS    AND    ITS    CLINICAL 

RELATIONS    TO    THE    ENVIRONING   NERVES,   TO 

WIT:    N.    OPTICUS,    N.    OCULOMOTORIUS,    N. 

TROCHLEARIS,  N.  TRIGEMINUS,  N.  ABDU- 

CENS  AND  N.   CANALIS  PTERYGOIDEI 

(VIDII),  AND  NASAL  GANGLION* 


Altlioui;h  liyperplastie  changes  within  the  nasal  fossae 
have  been  descril)ed  by  many  writers  and  although  special  at- 
tention has  been  given  to  the  study  and  description  of  this  mor- 


Cellulj.   ethmoidiaJis  [posterior] 


Sinus    fronts.1: 


FVotessus     front. 


Ductus  n&soljicri 


Fines    Ulerajis 


ocTjloraotorius 


ptery^oideus 
pal^tinzk.    descendens 


-ubi.  auditivft 
[Eust&chiiJ 


lus    ptery^oidcus 


Fklitinum    duruivJ 

5mus   maocill^ris 

Tig.   50. — Left   sagittal   section    5    mm.    lateral   to    sphenopalatine   foramen    showing   post-ethmoidal 
cell  /,  above  and  beyond  optic  nerve.     Viewed  from  without  inward. 

bid  process  in  the  ethmoidal  district,  no  mention  or  study  of 
this  process  in  the  sphenoidal  district  existed  until  1915  when 
I  presented  it  to  the  American  Lar^mgological  Association.®^ 
To  me  it  seems  a  matter  of  the  greatest  importance  and  far- 

*The    first    alhision    to    this    subject    by    me    was    in    an    article    read    before    the    American 
Laryngological   Association,    1912."* 

96 


HYPERPLASTIC    SPHEXOIDITIS 


97 


reaching  possibilities  because  of  the  iniiuiate  association  of  the 
many  nerve-trimks  in  the  region  of  the  hodij  of  the  sphenoid. 
In  1912  I'^  presented  tlie  anatomy  of  tliis  district  in  a  Avay 
differing  from  the  extant  descriptions  in  all  particulars.  These 
observations  were  confirmed  by  Dr.  Ladislaus  Onodi"  work- 


Fig.  51. —  Showing  prolongation  of  sphenoidal  sinus  around  optic  canal.     The  ligatures  are  passed 
under  the  optic  canal  and  anterior  clinoid  process. 

ing  by  a  different  method.  We  worked  indepeudently  and  un- 
kno^\m  to  each  other.  (He  did  not,  however,  observe  the  Vidian 
nerve  at  that  time.) 

Familiarity  mth  this  anatomical  detail  is  necessary  for 
the  purposes  of  this  essay. 

Anatomical  Relations. — The  body  of  the  sphenoid  bone  is 


98  HEADACHES    AISTU    EYE    DISORDERS    OF    NASAI.    ORIGIN 

usually  hollowed  out  by  the  sphenoidal  sinus.  This  cell  may, 
however  (rarely),  be  rudimentary  and  occupy  a  very  small 
space  in  the  lower  anterior  part  of  the  body,  which  is  otherwise 
holloAved  out  by  a  post-ethmoidal  cell,  or  the  body  may  be 
more  or  less  evenly  divided  by  these  cells.  It  is  of  the  cell 
which  hollows  the  body  of  the  s])henoid  that  I  write,  regardless 
of  whether  it  be  the  sphenoidal  sinus  proper  or  a  post-ethmoidal 
cell  or  both. 

The  body  of  the  sphenoid  is  covered  above  and  laterally 


Fig.  52. — Anterior  and  middle  fossae  of  skull  seen  from  above.  /.  Lesser  wing  of  the 
sphenoid  cut  ojien  just  lateral  to  the  anterior  clinoid  process  to  show  bristle  .'  passed  from 
the  sphenoidal  sinus  under  the  optic  canal  .,\  4.  r>ristle  from  a  post-ethmoidal  cell.  The  extent 
and  association  of  this  cell  with  the  optic  canal  is  shown  by  the  removal  of  the  cranial  plate 
exposing  the  optic  canal  j?  for  1.  cm..  5.  Floor  of  very  large  frontal  sinus  the  cranial  plate  of 
which   is   removed.     6.   Ethmoidal   cells. 

by  the  dura  mater,  \\'itli  the  cavernous  sinus  l)etween  its  exter- 
nal and  internal  surfaces  (in  it),  occupying  a  position  for  the 
most  part  above  and  lateral  to  the  l)ody.  The  optic  canal  is  sit- 
uated at  the  upper  outer  anterior  part  of  the  body  of  the  sphe- 
noid.    Its  inner  part  is  always  in  association  with  either  the 


HYPERPLASTIC    SPHENOIDITIS 


99 


Fig.  53. — Showing  an  older  representation 
of  the  sphenoidal  sinus  and  the  cavernous  sinus. 
/.  N.  oculomotorius.  2.  A^.  trochlearis.  j.  N. 
abducens.  5.  A',  maxillaris.  6.  Stvlotd  proc- 
ess   of    temporal    bone.       (After    Merkel.) 


Fig.  54. — Cross  transverse  section  of  the  cav- 
ernous sinus,  r.  Hypophysis.  2.  Internal  caro- 
tid artery.  3.  N.  abducens.  4.  Sphenoidal  cell. 
5.  X.  oculomotorius.  6.  X.  trochlearis.  7.  N. 
ophthalmicus.    S.  N.  maxillaris.     (After  Ouain.) 


Fig.   55. — The   usual    cavernous   sinus   with   large   cross  section    and   great   length.      Shows 

wide  separation   of  aJl   cranial   nerves   from   body    of  sphenoid.  /.   X.    oi>ticus.      -'.   X.    trochlearis. 

3.  N.     oculomotorius.      4.  X.    ophthalmicus.      5.   X.     abducens.  6.   Cavernous    sinus.      7.     Vidian 
canal. 


Fig.   56. — Cavernous   sinus   district.      (After   Rouber   and    Kopsch.) 

sphenoidal  simis  or  a  post-ethmoidal  cell.  And  not  infi'equently 
these  cells  send  a  prolongation  ontward  to  extend  more  or  less 
aronnd  the  canal  from  above  or  below  (Figs.  50,  51  and  52). 


100 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


The  optic  nerve  is  in  no  way  associated  with  the  cavernons  sinus. 
All  the  other  nerves  in  this  district,  i.  e.,  third,  fourth,  first 
and  second  divisions  of  lifth  and  sixth  are  in  association  with 


Fig.   57. — Cavernons    sinus    district.      /.   Foramen    magnum.      .'.   Cavernous    sinus.      3.   Crista   galli. 

(After  Piersol.) 


Fig.  58. — Left  middle  fossa  of  skull,  viewed 
from  above  and  to  the  left  showing  foramen 
ovale  separated  from  sphenoidal  sinus  3  by  thin 
bone  3.  (The  third  division  of  the  fifth  passes 
through  the  foramen  ovale.)  4.  Foramen  ro- 
tundum. 


Fig.  59. — Same  specimen  as  Fig.  42  viewed 
from  above  and  to  the  right.  /.  Foramen  ro- 
tundum.  J.  Bone  separating  sphenoid  cell  4, 
from  foramen  rotundum.  3.  Vidian  canal 
dehiscent    at    i)oint    of    indicator. 


it.  AVithin  the  cavernous  sinus  are  found  the  internal  carotid 
artery  and  the  third,  fourth,  and  sixth  cranial  nerves,  with  the 
first  division  of  the  fifth  lying  in  the  loAver  part  of  its  lateral 


HYPERPLASTIC    SPHEXOIDITIS 


101 


Avail.  The  impressioii  given  in  the  treatises  on  anatomy  is, 
usually,  that  those  nerves  are  rather  widely  seiDarated  from 
the  sphenoid  sinus,  as  shown  in  Figs.  53,  54,  55,  56,  and  57.  The 
second  and  third  divisions  of  the  fifth  and  the  Vidian  are  usually 
represented  as  Avell  removed  from  the  cell;  that  is,  separated 
by  a  considerable  tliickness  of  bone  (Fig,  53).  The  fact  is,  the 
sixth  and  third  division  of  the  fifth  are  the  onlv  ones  that  are 


lo-^ 


/ 


Fig.  60. — Top  view  of  left  si)lienoidal  district  dissected.  I.  Petrous  part  of  temporal 
bone.  2.  Semilunar  (Gasserian)  ganglion.  .?.  Foramen  spinosum.  4.  Foramen  ovale  with  man- 
dibular nerve  in  it.  Inside  the  sphenoid  cell  the  foramen  ovale  containing  the  mandibular  nerve  is 
marked  as  a  canal  5  mm.  long,  separated  in  a  semicircular  exposure  from  the  s])henoid  cell  by  bone 
1  mm.  thick.  5.  Abducent  nerve.  6.  Oculomotor  nerve.  ;.  Maxillary  nerve  entering  foramen 
rotundum.  5.  Trochlear  nerve.  9.  Ophthalmic  nerve.  10.  Inner'  limit  of  sphenoidal  fissure.  //. 
Opening  dissected  into-  sphenoidal  sinus.  /-'.  Optic  nerve.,  i^.  Ophthalmic  artery.  14.  Abducent 
nerve,  /j.  Internal  carotid  artery.  j6.  Posterior  clinoid  process.  //.  Clivus  of  Blumenbach. 
/S.  Abducent  nerve.  Dotted  line  shows  outline  of  sphenoidal  sinus.  It  is  separated  from  the 
overlying  structures  by  a  wall  of  bone,  eggshell  thin,  including  those  in  the  sphenoidal  fissure. 
The  inner  two-thirds  of  the  semilunar  ganglion  for  almost  one-half  its  length  are  also  included 
in)  this  close  association. 


not  at  times  in  close  association  with  this  cell;  that  is,  sepa- 
rated from  it  by  a  very  thin  layer  of  bone;  and  even  the  third 
division  of  the  fifth  is  sometimes  also  in  rather  close  associa- 
tion with  it  (Figs.  58,  59,  and  60).    The  sixth,  so  far  as  I  have 


10L> 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


found,  ill  the  cavernous  sinus  is  uniformly  placed  on  the  lat- 
eral aspect  of  the  carotid  and  always  removed  from  this  bony 
wall.  Thus  far  I  have  been  speaking  of  a  sphenoid  sinus  which 
is  limited  to  the  body  of  the  sphenoid.  Should  it  be  extended 
into  the  greater  wings,  the  sixth  nerve  may  come  into  close 
association  with  it  in  the  sphenoidal  fissure  below  (Fig.  60). 
Should  the  sphenoid  sinus  be  prolonged  backward  to  the  clivus 
of  Blumenbach  (Fig.  60),  the  sixth  will  be  in  very  close  asso- 


4 


y 


i-- 


Fig.  61. — Shows  a  sagittal  section  of  left  side  through  the  ophthalmic  nerve.  /.  Eu- 
stachian tube  with  bristle  in  its  lumen.  _'.  Tensor  palati  muscle,  j;.  Part  of  internal!  carotid 
artery.  4.  Semilunar  ganglion  in  Meckel's  cave.  5.  Pin  passed  through  wall  of  sphenoid.  6. 
Sphenoidal  sinus.  7.  Ophthalmic  nerve.  8.  Lesser  wing  of  sphenoid.  9.  Optic  nerve..  10. 
Post-ethmoidal  cell.  //.  Pterygomaxillary  fossa.  /-'.  Opening  dissected  into  maxillary  antrum. 
13.   Wall  of  nose.     14.  Internal   pterygoid   muscle. 


ciation  with  it  as.  it  passes  under  the  dura  mater.     This  was 
first  pointed  out  by  Ladislaus  Onodi.''^ 

The  fact  which  determines  the  relations  of  these  nerve- 
trunks  to  the  sphenoid  sinus  is  the  size  of  the  cavernous  sinus 
rather  more  than  the  size  of  the  sphenoid  sinus.  If  the  cavern- 
ous sinus  be  large  in  length  and  cross  section,  these  nerve- 
trunks  will  be  far  removed  from  contact  with  the  body  of  the 
sphenoid  and  the  sinus  within  it.  On  the  other  hand,  if  the 
cavernous  sinus  lie  small  in  length  or  cross  section,  these  nerve- 
trunks  may  be  closely  associated  with  a  sphenoid  sinus  limited 
to  the  body  of  the  sphenoid  bone.  Nerves  in  the  canals,  to 
wit,  the  optic,  maxillary  and  Vidian,  are  not  under  this  control. 


HYPERPLASTIC    SPHEXOIDITIS 


103 


Of  course,  a  small  sphenoid  sinus  in  the  center  of  the  body 
of  the  sphenoid  bone  will  be  widely  removed  from  contact  with 
these  nerve-trunks,  regardless  of  whether  the  cavernous  sinus 
be  large  or  small  (Fig.  53).  A  sphenoid  sinus  of  large  extent, 
prolonged  backward  and  outward,  may  readily  closely  approach 
the  third  division  of  the  fifth  in  the  foramen  ovale  (Fig.  58). 
and  Dr.  H.  P.  Mosher  has  loaned  me  two  specimens  in  which 
the  sinus  extended  to  a  close  association  with   the   semilunar 


Fig.  62. — /.  Sphenoidal  cell.  2.  Columnar  marking  of  the  internal  carotid  artery.  _  Note 
that  the  siihenoid  cell  extends  far  lateral,  to  this.  At  the  place  /  it  extends  to  the  region  of 
the  Gasserian   ganglion. 

ganglion.     I  too  have  found  such  specimens  and  here  report 
two  of  them  in  detail.*"    (Figs.  60,  61,  and  62.) 

The  semilunar  ganglion  is  at  present  thought  of  as  so  far 
removed  from  the  sphenoidal  sinus  that  they  have  not  been 
associated  in  the  minds  of  the  anatomists  or  clinicians.  The 
internal  carotid  art(M'y  usually  rises  on  the  lateral  aspect  of  the 
body  of  the  sphenoid  and  the  semilunar  ganglion  is  usually 
lateral  and  posterior  to  the  ascending  artery.  This,  however, 
is  not  always  true.  The  position  of  the  artery  seems  to  have  a 
large  part  in  determining  these  relations. 


104 


HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGUST 


I  present  drawings  of  two  specimens  showing  an  intimate 
association  of  the  sphenoid  sinus  to  the  semihmar  ganglion, 
or  parts  of  it.  Fig.  60  shows  dissection  of  the  caverons  sinns, 
semilunar  ganglion  and  sphenoidal  fissure  viewed  from  above. 
The  s^Dhenoid  sinus  lying  beneath  these  structures  is  shoA\ai  in 
dotted  line.  The  thickness  of  bone  separating  the  cavity  of 
the  sphenoid  from  these  structures  is  eggshell  thin.  The  inter- 
nal two-thirds  of  the  ganglion  are  exposed  to  the  uppermost 
part  of  the  sphenoid  cell  and  the  external  third  is  exposed  at 
a  little  greater  depth  as  the  nerve  tissues  approach  the  foramen 
ovale.     The  mandilmlar  nerve  in  the  foramen  ovale  is  exposed 


Fig.  63. — Showing  Vidian  exposed  in  R  sphenoid  sinns.  Cross  _  section  through  the 
pterygoid  processes.  /.  Left  sphenoid  cell.  2.  Vidian  canal.  ,?.  Pterygoid  process.  4.  Right 
sphenoid   cell.      6.   A   groove   marking  the   Vidian   canal.      Its    u[)per   part   is   missing. 


for  10  mm.  to  an  eggshell  bone  separation  from  the  si^henoicl 
cell. 

In  the  sphenoidal  fissure  the  oculomotor,  abducens  and 
ophthalmic  are  exposed  to  an  eggshell  separation  from  the  sphe- 
noid cell.  The  trochlearis  alone  is  not  in  this  contact  because 
it  lies  on  top  of  tlie  oculomotor. 

Fig.  61  sliows  a  sagittal  section  through  the  oculomotor 
nerve  within  the  cavernous  sinus.  The  specimen  is  viewed  from 
within  outward.  In  this  specimen  the  ganglion  is  exposed  on 
its  anterior  limit  for  10  mm.  to  an  eggshell  thin  bone  separa- 


HYPERPLASTIC    SPHEXOIDITIS 


105 


tion  from  the  sphenoid  sinus  at  the  origins  of  the  oplithahnie 
and  maxillary  divisions.  The  sphenoid  cell  measured  1.50  cm. 
sagittal,  4.50  cm.  vertical,  5.50  cm.  transversely. 

In  1912  I'®  proved  the  permeability  of  the  sphenoid  sinus 
wall  to  small  amounts  of  cocaine.     Following  this  observation,. 


ik. 


Fig.   64. — I.  Left    \'idian    canal    deficient    at    point    of    indicator. 

^.   Septum   sphenoidale. 


2.   Basilar    process    of    occiput. 


with  its  lesson,  into  these  anatomical  associations  seems  to  me 
to  offer  an  explanation  of  the  herpes  which  develops  in  the 
wake  of  sphenoidal  infections  or  which  arises  in  some  patients 
from  ordinary  coryzas  (irritation  of  the  sensory  ganglion  cells 


I 


^>•^ 


%'*.r 


^  ^7 


Fig.   65. — /.   Right   sphenoid   cell.      2.    1st   division   of   hfth  nerve.      ^.   2nd   division    of   fifth  nerve. 

being  necessary  f or  *the  development  of  heri^es),  and  to  explain 
why  semilunar  ganglion  neuralgias  and  tic-douloureux  of 
sphenoidal  origin  sometimes  recover  as  a  more  or  k^ss  acute 
or  subacute  lesion  and  at  other  times  require  a  ganglion  re- 
moval or  a  posterior  root  section;  i.  e.,  sometimes  the  sphenoid 
lesion  can  be  controlled  and  at  other  times  it  cannot. 


106 


HEADACHES   AISTD    EYE    DISORDERS    OF    NASAL    ORIGIiST 


A  sinus  extending  doAvnward  soon  approaches  the  Vidian 
nerve.  In  fact,  the  upper  side  of  the  bony  case  of  the  Vidian 
canal  is  often  partly  deficient  under  these  circumstances  (Fig. 
63).  The  excavation  may  also  extend  below  the  level  of  the 
canal  and  leave  it  stalking  tiirough  the  sphenoid  sinus  like  an 
ancient  aqueduct,  over  the  plain,  connected  with  the  bone  be- 
low by  a  paper-like  support  (Fig.  64).  Or  it  may  be  protected 
on  one  side  of,  and  exposed  on  the  floor  of  the  sinus  of  the  other 


Fig.   66. — Showing  paper-thin   separation   of  niaxiUary   nerve   in   foramen   rotundum   from  sphenoid 
sinus.      /.    Sphenoid  sinus,      j.    Foramen   rotundum. 


Fig.    67. — Cross    section    just    anterior   to    an-  Fig.    68. — Cross   section.      /.    Anterior   clinoid 

terior  clinoid  process.     /.   Lesser  wing  of  sphe-  process    right.        2.    N.    oculomotorius.        .?.    N. 

noid.      2.    N.    trochlearis.      .?.    N.    oculomotorius.  trochlearis.      4.   N.    ophthalmicus.     5.    N.    maxil- 

4.  N.  opticus.     5.  Anterior  beginning  of  cavern-  laris.     6.  Anterior  beginning  of  cavernous  sinus, 
ous  sinus. 


side  of  the  skull  (Fig.  63).  The  sphenoid  sinus  extended  lat- 
erally soon  reaches  the  foramen  rotundum  and  may  then  envi- 
ron one-half  of  its  circumference,  bringing  the  second  division 
of  the  fifth  at  this  point,  and  for  some  distance  posterior  to 
it,  into  very  close  association  with  it  (Figs.  65  and  QQ).  The 
third  and  fourth  nerves  are  in  close  association  with  the  ante- 


HYPERPLASTIC    SPHENOIDITIS 


107 


Fig.  69. — Cross  section  of  sphenoid  body  through  anterior  clinoid  iirocesses  posterior 
toi  optic  canals,  seen  from  in  front.  /.  Remnant  of  pharyngeal  tonsil.  2.  Anterior  outlet  of 
Vidian  canal  with  \'idian  nerve,  i.  Anterior  clinoid  process.  4.  Internal  carotid  artery  in  the 
cavernous  sinus  making  its  upturn.  5.  Riglit  sphenoidal  sinus.  6.  Left  sphenoidal  sinus.  ~. 
Foramen  rotundum  with  maxillary  nerve.  8.  Dotted  line  showing  the  prolongation  of  sphenoid 
sinus  outward  at  a  place  ijosterior  to  line  of  transverse  cut  showing  how  it  approaches  the 
foramen  rotundum.  9.  Sphenoid-vomer  junction.  10.  Line  of  sagittal  cut,  the  outer  portion 
of  which   is   shown   in   Fig.    70. 


Fig.  70. — Lateral  part  of  sagittal  section  through  line  10  of  Fig.  69.  /.  External  pterygoid 
muscle.  2.  Internal  carotid  artery.  S-  Oculomotor  nerve.  ^.  Ophthalmic  nerve.  5.  Cavernous 
sinus.  6.  Lateral  limit  of  sphenoidal  sinus.  7.  Bony  wall  of  sphenoidal  sinus.  8.  Tensor  palati 
muscle.  9.  Eustachian  tube  with  bristle  in  its  lumen.  10.  Tensor  palati.  ;/.  Internal  pterygoid 
muscle.      12.  Levator   palati   muscle. 


108 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIlSr 


rior  clinoid  process  or  lesser  wing  of  the  sphenoid,  which  are 
not  infrequently  hollowed  out  by  a  prolongation  of  the  sphe- 
noid sinus  or  (from  in  front)  by  an  extension  from  a  post- 
ethmoiclal  cell,  thereby  bringing  these  nerves  also  into  close 


Fig.  71. —  Sagittal  section  between  the  foramen  rotundum  and  Vidian  canal  right  side» 
viewed  from  without  inward.  /.  Hamular  process.  .?.  Tensor  palati  muscle.  5.  Levator  palati. 
4.  Eustachian  tube  with  bristle  in  its  lumen.  5.  Sphenoidal  sinus  prolonged  downward  into 
pterygoid  process  to  bifurcation  of  the  plates.  6.  Clivus  of  Blumenbach.  7.  Groove  for  carotid 
artery.  8.  Nasal  (internal)  part  of  sphenoidal  sinus,  g.  Vidian  canal  crossing  the  sinus.  10. 
Internal  carotid.  //.  Optic  nerve.  12.  Lesser  wing  of  sphenoid.  13.  Post-ethmoidal  cell.  14. 
Superior  rectus.  IS  Orbital  fat.  16.  Fronial  sinus,  ly.  Bristle  passed  from  maxillary  antrum 
through  its  outlet  into  middle  meatus  of  nose.  iS.  Hard  palate,  /p.  Maxillary  antrum  (nasal 
wall  seen  from  without).  20.  Nasal  ganglion.  3i.  Internal  pterygoid  muscle.  22.  Soft  palate. 
The  oi5tic  canal  in  this  specimen  is  surrounded  two-thirds  of  its  circumference  by  sphenoidal 
sinus  for  10  mm.   of  its  len:fth.     Observe  close  association  of  Eustachian  tube  to  sphenoidal  sinus. 

association  Avith  these  cells  (Fig.  67).  The  first  division  of  the- 
fifth  comes  into  close  association  Avith  the  siDhenoid  sinus  ante- 
riorly, if  the  cavernous  sinus  be  small  in  either  direction  (Figs.. 
65  and  68). 


HYPERPLASTIC    SPHEXOIDITIS  109 

The  relations  of  the  Eustachian  tnbe  to  the  sphenoidal  sinus 
were  described  by  me  in  1916.'"  In  the  nsnal  skull  the  tube  at 
all  points  is  far  (1.50  cm.)  removed  from  the  sphenoidal  sinus. 
Fig.  69  shows  a  transverse  section  througli  a  sphenoid  v,iiich 
seems  to  me  to  represent  a^-erage  large  sphenoid  cells.  The 
right  measures  2.25  cm.  transversely,  2  cm.  vertically,  and  2 
cm.  sagittal.  The  left  measures  2  cm.  transversely,  1  cm.  ver- 
tically, and  2  cm.  sagittal.  Fig.  70  shows  a  sagittal  section  of 
same  specimen  just  internal  to  the  foramen  rotundum.  The 
Eustachian  tube  (with  l)ristle  in  its  lumen)  is  seen  to  be  1.5  cm. 


J^tuwt"?.- 


Fig.  12. — Sagittal  section  of  specimen  shown  in  Fig.  73  through  the  maxillary  nerve. 
/.  Pterygomajcillary  fossae.  3.  Sphenoidal  sinus  prolonged  into  pterygoid  process  to  the  bifur- 
cation of  the  plates.  5.  Maxillary  nerve.  4.  Eustachian  tube  with  bristle  in  its  lumen.  5. 
Pterygoid  process.  The  dotted  line  of  F"ig.  S  is  shown  as  superimposed.  Observe  the  very 
close  association  of  ilustachian  tube  4  with  bristle   in  its   lumen  with  the  sphenoidal  sinus  _'. 

removed  from  the  nearest  approach  of  the  sphenoid  cell.  Such 
relations  preclude  that  a  prejudicial  effect  be  exercised  on  the 
tube  by  an  inflanmiatory  process  in  the  sphenoid. 

"When  the  sphenoid  cell  is  prolonged  downward  into  the 
pterygoid  process  it  approaches  the  Eustachian  tube  more  or 
less,  and  it  may  come  to  such  close  association  as  to  be  sepa- 
rated by  an  eggshell  thickness  of  bone  (Figs.  71,  72,  and  73). 
This  comes  through  two  factors,  first  the  thickness  of  the  bone 


110 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


of  the  pterygoid  process  is  absent,  and  secondly  tlie  origin  of 
the  tensor  palati  is  not  from  the  uppermost  limit  of  the  plate. 
Should  the  tensor  palati  arise  high  on  the  plate  the  thickness 
of  the  muscle  will  enter  in  between  the  tube  and  the  bone  of 
the  sinus  wall  (Fig.  74).  Should,  however,  the  tensor  extend  a 
lesser  distance  upward  on  the  plate  the  tube  comes  into  closer 
relation  and  in  some  specimens  is  in  contact  with  the  eggshell- 
thick  wall  of  the  sinus  (see  Figs.  71,  72,  and  73). 

Piersol   {Human  Anatomy,  1907,  p.  1503)   states  that  the 


Fig.  73. — Showing  the  nasal  (internal)  surface  of  specimen  shown  in  Fig.  72.  i.  Post- 
ethmoidal  cells.  -'.  Anterior  limit  of  sphenoidal  sinus.  3.  Sphenoid  sinus.  4.  Upper  limit  ot 
si)henoidal  sinus.  5.  Looking  into  lateral  part  of  sinus.  6.  Posterior  limit  of  sphenoidal  sinus. 
/".  Eustachian  tube  mouth.  8.  Soft  palate.  9.  Lower  limit  of  sphenoidal  sinus.  10.  \'idian  canal. 
//.  Hard  palate,     /i'.   Lower  turbinate.     The  dotted  line  of  Fig.   72  is  shown  in  the  depths. 

glands  of  the  membrane  lining  tiie  tube  pierce  the  depths  to 
perforate  the  clefts  in  the  cartilage  extending  into  the  environ- 
ing connective  tissue. 

In  1912  I  proved'^  the  permeability  of  the  thin  sphenoidal 
wall  by  an  intrasphenoidal  application  of  cocaine,  paralyzing 
the  entire  fifth  nerve.  Such  permeal)ility  it  seems  to  me  would 
allow  an  irritation  in  the  tubes  in  such  a  case  as  Figs.  71,  72, 
and  73  as  long  as  the  sphenoidal  inflammation  continued.     I 


HYPEEPLASTIC    SPHENOIDITIS 


111 


believe  this  is  the  explanation  of  some  surprisingly  fine  re- 
sults for  abandoned  cases  of  low  grade  deafness  following  post- 
ethmoidal  sphenoidal  surgery.  I  have  previously  thought 
these  cases  to  have  been  crippled  Vidian  nerves  from  sphenoid 
sinus  inflannnation — the  great  superficial  petrosal  nerve  from 
the  geniculate  ganglion  of  the  seventh  (part  of  the  Vidian) 
being  the  motor  supply  to  the  tensor  and  levator  palati — they 
being  thereby  unable  to  perform  their  full  functions  so  that 
these  muscles  did  not  open  the  tube  properly. 


Fig.  74. — Sagittal  section  lietwecn  foramen  rotundum  and  \'idian  canal,  viewed  from 
without.  /.  Hamular  process.  .'.  Internal  pterygoid  muscle.  3.  Lower  meatus.  4.  Middle 
meatus.  5.  Nasal  ganglion.  6.  Upper  meatus.  7.  Optic  nerve.  8.  Sphenoidal  sinus,  g.  X'idian 
canal.  10.  Abducent  nerve.  11.  Internal  carotid  artery.  12.  Internal  carotid.  13.  Tensor  pa- 
lati muscle.  14.  Eustachian  ti;be  with  bristle  in  its  lumen.  j/j.  Palatopharyngeus  muscle. 
16.   Levator  palati.  ■  //.    Soft  palate. 

Observe  12  mm.  separation  of  Eustachian  tube  14  from  sphenoidal  sinus  S  des])ite  the 
prolongation  of  the  latter  into  the  pterygoid  process  to  the  bifurcation  of  the  plates.  In  this 
case  the  tensor  palati  rises  high   and   seijarates   them. 


I  believe  both  explanations  are  correct  in  two  types  of 
cases  respectively. 

Clinical  Relations. — Clinically  the  inflannnatory  diseases 
of  the  ])aranasal  cells  vary  greatly.  Each  has,  however,  some 
semblance  of  constancy  in  its  behavior,  at  least  as  far  as  symp- 
toms with  signs  go,  with  the  excejDtion  of  the  sphenoid.  As  is 
known  to  us,  it   is  no   unconnnon  thing  to  see  a   sphenoidal 


112  HEADACHES    AXD    EYE    DISORDERS    OF    XASAL    ORIGIN 

empyeiiia  give  rise  not  only  to  its  own  characteristic  symiotoras, 
1bnt  to  simulate  the  pains  prodnced  by  all  the  other  sinuses. 
Pain  of  a  frontal  sinns  inflammation  may  he  simnlated  hy  a 
sphenoidal  inflannnation — the  differential  diagnosis  being  made 
by  the  absence  of  pus  from  the  frontal,  with  no  tenderness  of  its 
iloor — "Ewing's  sign" — as  well  as  a  negative  finding  on  the 
x-ray  picture.  The  pain  of  a  maxillary  antrum  inflammation 
may  be  differentiated  by  a  negative  antrum  puncture  as  well  as 
a  negative  x-ray  picture.  Absence  of  pus  in  or  from  the  ethmoid 
would  exclude  the  ethmoidal  cells.  These  symptoms,  Avhen  pro- 
duced by  the  sphenoid,  are,  however,  more  apt  to  be  nocturnal 
llian  diurnal. 

It  seems  to  me  there  are  two  pictures  produced  l)y  inflam- 
matory disease  of  the  sj^henoid  sinus.  The  primary  simple  one 
is  that  produced  by  the  pressure  from  an  obstructed  outflow  of 
pus.  I  have  construed  this  as  the  explanation  of  the  somewhat 
"dull,"  "heavy"  x^ain  in  the  back  of  the  head  described  by 
ihese  patients.  The  more  complex  one,  simulating  the  pains 
which  are  ordinarily  produced  by  the  other  sinus,  can  only  be 
explained  by  assuming  that  the  associated  nerve-trunks  have 
hecome  involved  either  l)y  the  inflainmatory  process  or  by  its 
toxins.  This  assumption  applied  to  the  third  nerve  may  ex- 
plain also  the  dilated  pupil  seen  in  some  of  these  cases,  when 
the  ophthalmologist  or  neurologist  can  assign  no  reason  for 
it;  and  the  asthenopia  that  is  sometimes  met  Avitli  when  no 
reason  may  be  found  in  the  eye  or  nose,  otherwise.  Some  of 
these  cases  show  a  xDaresis  of  the  superior  oblique. 

From  the  above  described  anatomy,  in  which  the  s|)henoid 
sinus  is  separated  from  the  nerve-trunks  by  thin  divisions  of 
l)one,  such  an  extension  of  inflammation  might  easily  occur. 
In  an  effort  to  prove  the  accessibility  of  these  nerve-trunks  I 
have  often  x^ainted  the  cavity  of  the  sx^henoid  in  a  strix^e  from 
above  downward  and  outAvard  with  a  very  small  applicator 
hearing  about  one-half  to  one  drop  saturated  water  solution  of 
cocaine  (90%)  and  x^aralyzed  one  or  all  three  divisions  of  the 
fifth  for  tactile  sensation  and  x^ain,  accomxianied  by  a  marked 
sense  of  stiffness  of  the  lower  jaw  on  that  side.  A  needle  could 
be  passed  through  the  skin  supplied  by  these  nerves  and  fail 
to  evoke  sensation.     In  these  cases  the  sex:)arating  wall  must 


HYPERPLASTIC    SPHENOIDITIS  113 

have  been  a  very  thin  one,  thereby  permitting  the  cocaine  to 
pass  quickly  and  easily  throngh  to  the  nerve-trmiks.  I  have 
also,  for  therapeutic  purposes,  filled  the  sphenoid  ^yiih  oil  so- 
Intions — 1  per  cent  phenol,  2  per  cent  menthol,  5  per  cent  and 
10  per  cent  oil  of  wintergreen  and  1  ]ier  cent  cocaine  alkaloid — 
and  found  that  they  all  produce  a  well-defined  analgesia  of  the 
second  and  sometimes  the  first  and  the  third  divisions  of  the 
fifth,  accompanied  by  very  little  or  no  tactile  anaestliesia.  It 
therefore  seems  to  me  reasonable  to  assnme,  when  the  diagnosis 
is  sphenoid  empyema  and  the  symptom  is  pain  in  the  brow, 
that  it  is  inflammation  or  irritation  of  the  first  division  of  the 
fifth  by  the  process  within  the  sinns  which  makes  the  symptom. 
When  the  symptom  is  pain  in  the  npper  jaw  and  teeth,  or  tem- 
ple, it  seems  reasonable  to  assume  the  second  division  of  the 
fifth  has  l^ecome  involved.  ^Mien  the  symptom  is  pain  in  the 
lower  jaw  and  teeth,  accompanied  by  a  sense  of  stiffness  in  the 
jaw  on  that  side,  it  may  be  assumed  that  the  third  division  has 
become  involved  and  that  probably  in  the  foramen  ovale. 

The  behavior  of  certain  sphenoid  empyemata  has  inter- 
ested me  much  for  several  years.  These  are  cases  in  which  the 
pains  and  aches  have  continued  unchanged,  despite  wide  open- 
ing of  the  cavities  and  cessation  of  all  pus  or  signs  of  local  dis- 
ease. It  is  my  habit  to  perform  a  radical  post-ethmoidal  sphe- 
noidal operation  (see  page  164).  It  seems  to  me  the  most 
comprehensive  treatment.  Some  of  these  cases,  however,  al- 
though recovering  from  the  suppurative  inflammation,  and 
later  from  all  signs  and  symptoms,  have  frequently  subse- 
quently developed  headache  and  behaved  as  cases  of  migraine. 
Dr.  M.  A.  Bliss  has  seen  a  number  of  these  cases  in  consulta- 
tion, and  has  sent  some  of  them  to  me  and  has  agreed  in  the 
diagnosis  of  migraine.  I  have  felt  that  in  this  class  of  cases 
Avhicli  have  simulated  and  borne  the  name  of  migraine,  the 
■origin  of  the  pain  Avas  a  local  one.  These  are  of  similar  symp- 
tom-complex to  those  of  toxic  origin.  The  distribution  of  the 
pain  has  been  that  suggesting  as  its  origin  the  first  division  of 
the  fifth,  as  well  as  the  second  division,  sometimes,  or  the  third 
division,  and  combined  at  times  with  the  posterior  pain,  wliich 
I  have  attributed  to  the  irritation  of  the  Vidian.  In  a  recent 
paper^^  I  mentioned  that  in  the  injection  of  the  nasal  ganglion 


114  HEADACHES    AXD    EYE    DISORDERS    OF    I^ASAL    ORIGIX 

with  alcohol,  when  the  needle  was  placed  too  far  internal,  the 
pain  produced  by  the  alcohol  was  projected  baclvAvard  and  into 
the  shoulder,  etc.,  and  when  placed  too  far  external  the  pain  was 
referred  to  the  npper  jaw;  that  is,  when  the  side  of  the  gan- 
glion upon  which  the  Vidian  enters  was  injected,  the  pain  Avas 
referred  postei'ioi'ly,  whereas  Avith  the  side  upon  which  the  sec- 
ond division  entered,  the  pain  was  referred  to  the  upper  jaw. 
AVhen  the  alcohol  was  placed  in  the  ganglion  direct,  the  pain 
was  referred  in  both  directions.  (The  relative  position  of  the 
Vidian  and  second  division  of  the  fifth  is  shown  in  Fig.  39, 
which  portrays  the  foramina  through  which  they  pass  at  these 
points.  Faradic  stimulation  of  the  Vidian  produces  pain  in  the 
ear,  mastoid,  neck,  shoulder,  etc.     (See  Chapter  II.) 

These  cases  of  recent  origin  (three  to  six  months  approxi- 
mately) when  Avell  of  tlie  suppuration,  Avere  usually  Avell  of  all 
symptoms  and  remained  so  until  a  coryza  infected  the  general 
nasal  cavity,  Avlien  they  again  deA^eloped  their  pains,  often  Avitli- 
out  suppuration  of  the  sphenoidal  and  post-ethmoidal  cells. 
The  membrane  of  the  sphenoidal  sinus,  hoAvcA'er,  usually 
shoAved  under  these  circumstances  a  red  swollen,  or  edematous 
condition  (eA^en  polypoid)  analogous  to  that  shown  by  the  ante- 
rior ethmoidal  region  in  hyperplastic  ethmoiditis  imder  sim- 
ilar inflammatory  influences ;  that  is,  clinically  it  is  hyper- 
plastic sphenoiditis.  In  the  recoA^ery  the  sAvelling  and  edema 
would  subside,  but  more  or  less  of  the  pain  Avould  continue,  and 
at  a  time  later  begin  a  cyclical  reappearance,  Avitli  no  visible 
disturbance  in  the  sphenoid  sinus,  even  when  its  anterior  Avail 
had  a  permanent  opening  in  it  large  enough  to  permit  a  good 
view  of  its  interior.  I  did  not,  lioweA^er,  at  this  time  emx^loy 
Holmes'  nasopharyngoscope.  Use  of  this  instrument  later 
showed  that  patches  of  inflammation  within  the  sinus  are  usu- 
ally discoA'erable  on  the  floor  or  loAver  lateral  part  of  its  Avails. 
The  Vidian  canal  Avith  the  Vidian  nerve  is  on  the  floor,  and 
the  foramen  rotundum,  containing  the  maxillary  nerve  is  at 
the  loAver  lateral  anterior  part  of  the  l)ody  of  the  sphenoid.  I 
have  obserA'ed  a  similar  behavior  of  the  nasal  ganglion ;  i.  e., 
intermittent  reappearance  of  the  neuralgia  usually  Avith  an  in- 
flamed spot  at  the  sphenopalatine  foramen.  I  haA^e  also  ob- 
served in  these  sphenoidal  cases  a  picture  identical  Avitli  the 


HYPERPLASTIC    SPHENOIDITIS  115 

neuraloia  wliicli  starts  in  the  nasal  ganglion.  This  is  not  sur- 
prising, on  the  contrary,  Avonld  be  expected  after  one  has  proved 
the  accessibility  of  these  nerve-trunks.  The  entire  nerve  supply 
of  that  ganglion,  to  wit,  the  second  division  of  the  fifth  and  the 
Vidian  nerve,  l)eing  so  closely  associated  with  the  sphenoid 
sinus,  the  picture  of  the  ganglion  neuralgia  is  readily  repro- 
duced under  inflannnatory  conditions  within  the  sinus.  The 
differential  diagnosis  is  made  by  the  facts  that  cocainization 
of  the  ganglion  stops  the  pain  when  it  is  made  in  the  ganglion, 
but  fails  to  stop  it  when  it  is  made  in  the  sphenoid,  because 
the  ganglion  is  peripheral  to  that  point  of  origin;  and  that  co- 
caine solution  applied  within  the  sphenoid  sinus  does  stop  the 
pain.  In  the  case  of  ganglion  neuralgia,  the  membrane  cover- 
ing the  sphenopalatine  foramen  is  usually  but  not  always,  con- 
gested and  thickened.  This  appearance  may  be  absent  in  the 
case  Avhere  the  pain  is  started  in  the  nerve-trunks  from  within 
the  sinus. 

I  have  seen  this  class  of  sphenoidal  cases  behave  as  vaso- 
motor rhinitis  or  rhinorrhea  or  "'hay  fever,"  as  the  patients 
call  that  form  of  paroxysmal  sneezing,  accompanied  by  profuse 
Avatery  discharge  and  by  asthma.  In  these  cases  all  therapeu- 
tic measures  applied  peripherally  (intranasal)  were  of  no  avail. 
They  yielded  to  intrasphenoidal  ai3plications. 

In  the  observation  of  these  cases  I  am  led  to  the  belief  that 
a  large  number  of  the  frequently  recurring  headaches,  of  what- 
ever length  of  time  standiiig,  that  usually  bear  the  name  ''mi- 
graine," that  are  met  with  in  the  general  practice  of  medicine, 
that  have  defied  diagnosis  and  treatment,  are  sphenoidal  in- 
flammations existent,  or  were  started  as  such.  They  may  have 
lost  all  the  evidences  of  local  disease,  which  some  months  or 
years  before  were  easily  recognizable.  I  believe  that  the  sen- 
sory and  sympathetic  nerve-trunks  have  become  diseased  from 
juxtaposition,  just  as  the  optic  is  known  to  do.  Disease  of 
the  nerve-trunks  under  these  circumstances  is  in  no  Avise  dif- 
ferent in  its  clinical  behavior  fi'om  that  whicli  is  started  fur- 
ther toward  the  periphery,  as  for  instance,  from  an  antrum  of 
Highmore  suppuration  or  a  diseased  tooth,  which  after  the  cure 
of  the  local  disorder  continues  painful  at  intervals  or  becomes 
a  tic-douloureux.     The  second  division  of  tlie  fiftli  in  the  fora- 


116  HEADACHES    AISTD    EYE    DISORDERS    OF    NASAL    ORIGIN 

men  rotiindum  is  in  as  close  association  with  the  sphenoid 
sinns  as  is  the  optic  nerve  in  the  optic  canal,  and  under  iden- 
tical setting,  namely,  surrounded  completely  by  a  firm,  bony 
ring.  This  is  true  of  the  third  division  of  the  fifth  also ;  but  it 
is  not,  as  a  rule,  so  closely  associated  with  the  sphenoid  sinus. 
Optic  nerve  disease,  secondary  to  the  sinus  disease,  is  too  well 
known  and  proved  to  recpiire  argument  here.  I  see  no  reason 
why  we  may  not  assume  as  much  for  tlie  other  nerve-trunks, 
in  close  association  with  these  sinuses,  with  the  difference  be- 
tween the  types  of  nerves.  This  sphenoidal  area  being  central 
to  the  place  of  injection  of  alcohol  into  the  branches  of  the 
fifth  nerve,  from  under  the  zygoma,  may  explain  some  of  the 
cases  that  have  not  been  relieved  by  that  treatment.  Also,  for 
the  same  reason  can  we  undei'stand  that  when  the  semilunar 
ganglion  has  become  involved  and  gives  rise  to  the  pain,  intra- 
sphenoidal  applications  will  fail  to  relieve. 

The  involvement  of  the  nerve-trunks  in  the  sphenoidal  dis- 
trict producing  the  sneezing  explains  Avliy  the  injection  of  the 
branches  in  the  neighborhood  of  the  sphenopalatine  foramen 
(Stein^^),  combined  with  the  same  treatment  of  the  anterior 
nerves,  has  failed  to  influence  the  sneezing  in  some  cases,  the 
sphenoidal  area  being  central  to  the  other  nerves. 

It  appears  that  whatever  may  be  the  lesion  of  the  nerves, 
it  is  rather  easily  remediable  in  its  earlier  stages  by  intra- 
sphenoidal  medication.  The  worst  cases  by  sedulous  treatment 
may  be  greatly  improved  if  not  cured. 

I  have  not  thus  far  been  able  to  secure  any  post-mortem 
material  bearing  on  the  above  question.  This  happens  because 
we  as  rhinologists  are  apt  to  see  the  patient  only  while  he  is 
in  good  general  health.  Later  in  life  when  his  general  health 
fails  he  seeks  the  help  of  the  internist  and  dies  in  his  charge 
unkno\\Ti  to  us.  We  learn  of  his  deatli  only  some  time  later.  In 
the  public  hospitals  the  chief  ol^stacle  to  securing  this  mate- 
rial is  the  antagonism  of  the  undertakers  to  any  form  of  au- 
topsy.    They  seem,  somehow,  to  l)e  a))le  to  accomplish  this. 

That  the  cavernous  sinuses  may  become  infected  and 
thrombotic,  secondary  to  sphenoidal  infection,  is  well  known. 
In  these  considerations  the  cavernous  sinus,  however,  plays 
only  an  anatomical  part. 


HYPEEPLAkSTIC    SPHENOIDITIS  117 

I  have  stated  in  the  records  of  some  of  these  cases  that 
they  behave  as  a  hyperphistic  ethmoiditis,  and  that  some  did 
not.  So  far  as  I  have  been  able  to  learn,  there  is  no  post- 
mortem histologic  proof  of  a  hyperplastic  process  in  the  sphe- 
noid such  as  has  been  proved  in  the  ethmoid. 

Hyperplastic  disease  in  the  nose  involves  not  only  the  bone 
l)nt  the  soft  parts  covering  it,  in  the  nose  and  in  the  paranasal 
cells,  as  shown  often  at  the  time  of  operation  by  polyps  within 
tlie  cells.  AYhether  such  changes  ever  occur  on  the  orbital  side 
of  the  ethmoid  or  maxillary  antrum  or  the  dural  side  of  the 
sinuses,  is  a  question  I  have  not  as  yet  been  able  to  solve.  A 
case  reported  by  \V.  B.  Chamberlain^"  indicates  that  polyps 
may  form  in  the  cranium. 

The  conchisions  liere  recorded  are  the  results  of  examina- 
tions of  bone  removed  from  185  such  cases  in  my  own  ptractice ; 
and  I  have  been  assisted  by  Dr.  Jonathan  Wright's  examina- 
tions and  conclusions  regarding  the  microscopic  changes  in 
them. 

The  clinical  diagnosis  of  hyperplastic  sphenoiditis  is  con- 
firmed by  Dr.  Wright  from  the  examination  of  the  anterior  and 
inferior  s^Dhenoidal  ^^^^alls  removed  from  these  cases.  Further- 
more, Dr.  Wright's  conclusions  passed  upon  the  bone  sections 
from  these  cases,  whose  histories  were  unknown  to  him,  cor- 
responded so  closely  with  their  history  before  and  after  oper- 
ation as  to  be  very  striking.  The  list  comprises  those  oper- 
ated for  suppuration  of  longer  or  shorter  standing  without 
other  sjmiptoms,  which  1  feel  should  ])e  classed  as  the  simplest 
cases;  and  others  operated  for  pus  with  more  or  less  headache 
and  of  longer  (six  months)  or  shorter  (two  months)  standing 
whicli  were  mild  cases;  and  otliers  for  ticute  exacer])ation  with 
suppuration  and  others  for  acute  ocular  involvement  and  some 
totally  blind  with  little  or  no  disc  changes;  some  Avith  transi- 
tory amblyopia;  some  with  choroiditis  simple,  and  others  of 
this  class  Avith  ocular  palsies  also,  third,  fourth,  and  sixth 
nerves,  Avhich  are  of  the  type  of  ophthalmoplegic  "'megrim"; 
others  of  many  months  or  years  standing  without  pus,  Avith 
slight  disc  SAvelling  sloAvly  increasing  Avith  a  narroAving  visual 
field;  some  Avitli  choroidal  hemorrhages  and  total  clouding  of 
the  uveal  media;  some  serous  iritis  and  cyclitis  and  anterior 


118  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

eliamber  liemorrliages,  others  without  ])ns  but  witli  sensory 
(fifth)  trunk  involvements  (hypaesthesia)  and  recurrent  head- 
ache of  the  type  (severe)  vulgar  migraine,  without  and  with, 
pallor  (sympathetic  migraine),  and  one  recurrent  headache 
with  loss  of  consciousness,  of  ten  years'  standing  of  the  type 
of  epileptic  migraine;  and  sixteen  with  ophthalmic  migraine, 
complete  pictures  of  all  grades,  four  with  great  headache  and 
hallucinations,  the  type  of  psychical  migraine,  and  eight  major 
epilepsies  (one  cured  18  years).  Most  Avere  uncomplicated  by 
systemic  conditions.  Some,  however,  occurred  in  the  course  of 
nephritis  and  a  number  in  arteriosclerosis  and  heightened 
blood-pressure,  and  some  with  arthritis  deformans;  some  Avith 
severe  digestive  disorders  and  some  in  syphilitics.  All  sys- 
temic conditions  seemed  to  have  so  little  influence  on  the  local 
conditions  as  to  be  unrecognizable.  The  length  of  time  over 
which  these  cases  have  been  observed  varies  from  nineteen  years 
to  twenty-three  months. 

Intrasphenoidal  observation  with  Holmes'  nasopharyngo- 
scope-*  after  the  anterior  wall  was  removed  has  showTi  thick- 
ening of  the  membrane,  and  sometimes  a  marked  sclerotic  state, 
and  often  localized  inflammation,  and  sometimes  polyps  or  cysts 
within  the  sinus,  and  sometimes  vessels  entering  and  leaving 
the  sinuses  through  that  part  of  the  wall  which  makes  up  the 
optic  canal.  Furthermore,  the  configuration  of  the  sinus  can 
often  be  made  out  accurately,  especially  the  most  important 
parts.  These  are  more  or  less  at  a  right  angle  to  the  shaft  of 
the  instrument,  which  is  the  direction  in  which  the  prism  looks ; 
e.  g.,  the  regions  of  the  optic  canal,  foramen  rotundum  and 
Vidian  canal.  As  the  instrument  is  now  constructed  it  has 
the  defect  that  it  cannot  look  forward  or  backward  more  than 
its  60°  visual  angle  (30°  to  each  side  of  the  perpendicular) 
and  requires  a  cell  12  mm.  front  to  back,  to  contain  its  light 
and  prism,  as  Dr.  Gundelach  has  stated.  It  has,  however,  been 
of  much  help  in  the  understanding  of  these  cases  as  well  as 
determining  the  comprehensiveness  of  my  post-ethmoidal- 
sphenoidal  operation.  By  these  means  I  have  been  able  to  con- 
firm the  diagnosis  of  hyperplastic  sphenoiditis  by  intra-sphe- 
noidal  observation  and  to  learn  that  the  process  is  }wt  always 
universal,  and  that  the  exacerbations  wliich  may  take  place  in 


HYPERPLASTIC    SPHENOIDITIS  119 

this  district  from  coryzas  may  be  localized;  and  that  accord- 
ing to  their  position  they  may  be  more  or  less  pernicious  or 
disastrous;  e,  g\,  when  localized  about  the  optic  canal  they  may 
impair  vision  icithout  other  s'imptorns;  or  when  localized  on 
the  tower  tatter  aspect  of  the  sinus  they  may  cause  maxillary 
neuralgia;  or  on  the  floor  they  may  give  rise  to  Vidian  neu- 
ralgia of  any  grade.  I  use  the  term  "Vidian  neuralgia"  to 
express  pain  in  the  ear,  mastoid,  occiput,  neck,  shoulder  blade, 
shoulder,  arm,  forearm  and  hand  l^iecauso  I  found  on  experi- 
ments upon  the  nasal  ganglion  that  it  could  lie  produced  by  the 
faradic  current  attached  to  the  needle  Avhen  /;/  situ  for  injec- 
tion of  the  ganglion  and  that  it  could  be  produced  separately 
from  the  anterior  or  maxillary  part  of  the  s^miptom-complex 
(pain  in  the  teeth,  eye  and  temple),  l)y  inserting  the  needle 
into  the  Vidian  on  the  internal  side  of  the  ganglion.  The  de- 
pressing peculiarity  of  this  pain  has  been  emphasized  by  M. 
A.  Bliss. ^  Marked  anaphrodisia  poAver  has  l)een  ascribed  to  it 
l)y  some  patients. 

In  considering  hyperplastic  sphenoiditis  as  a  pathological 
process  with  the  part  it  plays  clinically,  I  feel  that,  primarily, 
attention  should  be  called  to  the  anatomy  of  these  parts,  as 
recorded  above.  The  relations  of  the  optic  canal  with  the  con- 
tained optic  nerve,  to  that  cell  are  at  once  important  and  strik- 
ing and  have  been  remarked  upon  l)y  many  observers,  notably 
Emil  Berger  r  and  latterly  emphasized  by  A.  Onodi,''-  and  again 
by  H.  "\V.  Loeb,*^  who  has  furnished  us  with  the  best  pictures 
T  have  seen  of  that  district  and  its  variations. 

Attention  to  the  anatomical  relations  of  the  sphenoid  cell 
to  the  foi-amen  rotnndum  containing  the  maxillary  nerve,  and 
the  foramen  ovale  containing  the  mandibular  nerve,  and  Vid- 
ian canal  containing  the  Vidian  nerve,  as  well  as  the  clinical 
importance  of  these  relations  was  directed  for  the  first  time 
in  my  above  cited  text.'^  Those  anatomical  observations  were 
confirmed  by  Ladislaus  Onodi,  working  by  a  different  method. 
Our  results  "were  published  ^tay  11,  1912,^^  and  July  10,  1912,**^ 
respectively,  except  for  the  Vidian  nerve,  which  he  did  not  at 
that  time  consider  as  I  remarked  above.  Later  he  confirmed 
the  Vidian  relations.  Dr.  Onodi  in  this  latter  text"-  refers  to 
mv  observations  numbered  in  these  references  78  and  81  A.    He 


120  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGUST 

lias,  however,  made  mistakes  possibly  explicable  by  differences 
of  language,  which  require  correction:  i.  e.,  text  No.  78  was  not 
a  "lecture"  but  presented  as  an  official  communication  to  the 
American  Laryngological  Association  at  its  Thirty-fourth  An- 
nual Meeting,  held  in  Atlantic  City,  N.  J.,  May  9  to  11,  1912. 
The  presentation  was  accompanied  by  the  drawings  which  were 
published  with  the  text  as  well  as  the  specimens  from  which  the 
clraAvings  were  made,  no  mention  of  Avhicli  has  hitherto  seemed 
to  serve  a  purpose.  In  his  citation  of  the  second  text  (No.  81  A) 
he  has  made  a  mistake  as  to  whose  researches  are  recorded  in 
that  text.  The  determination  of  the  age  at  wliich  the  sphenoidal 
sinus  reaches  close  relations  to  the  foramen  rotundum  with 
the  maxillary  nerve  and  Vidian  canal  with  the  Vidian  iierve 
was  made  by  me  and  not  b}^  Dr.  Davis.  Through  personal 
favor  Warren  B.  Davis  allowed  me  to  examine  his  matchless 
collection  of  Caucasian  specimens  Avith  the  understanding  that 
I  might  enjoy  the  privilege  of  recording  my  observations,  giv- 
ing him  credit  for  the  material.  At  that  time  Dr.  Davis  was 
not  interested  in  the  foramina  and  canals  or  nerve-trunk  re- 
lations to  the  body  of  the  sphenoid.  His  desire  was  to  con- 
tribute to  anatomy  a  full  and  accurate  knowledge  of  the  ''De- 
velopment and  Anatomy  of  the  Nasal  Accessory  Sinuses  in 
Man"  (to  cpiote  the  title  of  his  monograph,  1914),  and  he  did 
this  with  a  completeness  and  an  accuracy  that  surpassed  all 
description  or  portrayal  extant.  And  so  it  was  that  he  had 
definitely  determined  tlie  beginning  and  the  manner  of  the  de- 
velopment of  the  s])henoidal  sinus,  Init  he  was  not  concerned 
with  its  approach  to  the  foramen  rotundum  or  the  Vidian  canal,, 
nor  did  he  realize  any  clinical  significance  or  importance  in 
those  relations.  I  attempted  to  make  this  clear  in  my  text.  In 
addition  to  differences  in  the  languages  (which  make  mistakes 
very  easy)  these  points  might  have  l)een  brought  forth  with 
greater  emphasis,  which  did  not,  however,  seem  to  me,  at  the 
time  to  be  necessary. 

The  statement  is  made  in  Dr.  Onodi's  text  that  his  ob- 
servations were  first  published  in  ''Orvosi  Hetilap,"  March  24^ 
1912.  Perusal  of  that  journal  shows  his  text  to  have  been  pub- 
lished November  3,  1912. 

Dr.  Onodi  and  I  made  some  similar  observations.     Mine 


HYPERPLASTIC    SPHEXOIDITIS  121 

were  made  as  a  necessary  chapter — the  applied  anatomy — in  a 
very  diffienlt  and  complex  clinical  prohlem.  The  question  of 
the  adjacent  foramina  and  canals  was  at  that  time  a  matter 
of  importance  and  record  for  me  and  has  g■ro^,^^l  constantly 
more  important.  I  do  not,  however,  regard  tlie  nerve  contacts 
A\dth  decreasing  importance.  Dr.  Onodi's  method  was  to  fol- 
low the  nerve-trunks  in  their  courses  and  when  found  in  con- 
tact with  the  l)one  to  measure  the  lengths  of  such  contacts  and 
note  the  thickness  of  the  hone  separating  the  trunks  from  the 
sphenoid  sinus,  and  I  helieve  this  to  be  very  valuable  contri- 
bution to  our  knowledge  of  this  district.  He  did  not  consider 
the  foramina  or  canals  or  the  part  played  by  the  cavernous 
sinus  in  determining  the  contacts.  I,  too,  had  tried  that  method, 
but  in  my  hands  it  was  less  satisfactory  than  the  method  by 
serial  cross  section  of  this  district,  using  material  carefully 
hardened  in  formaldehyde  and  decalcified  in  dilute  HCl.  Such 
material  may  be  sectioned  Avith  a  good  knife,  as  thin  as  1.5 
nun.,  or  even  1  mm.  when  desired.  These  sections  when  ex- 
amined with  magnifying  glasses  Mere  most  satisfactory.  The- 
macerated  bones,  too,  in  some  instances  were  advantageous. 
The  cross  sections  have  the  advantage  that  they  determine  all 
contacts  most  accurately  as  well  as  tlie  relations  of  the  fora- 
mina and  canals  and  the  thickness  of  the  separating  bone.  They 
also  give  an  estimate  of  the  amount  of  fat  or  connective  tissue 
surrounding  the  nerves  in  tlie  foramina  and  canals. 

In  my  text,'*  hyperplastic  sphenoiditis  Avas  referred  to  as 
being  in  my  opinion  the  lesion  underlying  many  of  the  recur- 
rent headaches,  in  healthy  people,  which  at  present  bear  the- 
name  ''migraine."  I  spoke  of  this  class  of  cases  again  at 
the  meeting  of  the  American  Lar^mgological  Association  in  1913 
and  again  at  its  1914  meeting,  explaining  some  of  its  features. 
Its  (hyperplastic  sphenoiditis)  very  great  importance  in  the 
life  of  the  patient  and  its  far-reaching  pernicious  possibili- 
ties were  not,  hoAvever,  so  clearly  impressed  upon  me  then 
(1912)  as  now.  At  that  time  I  thought  that  many  of  the  cases, 
if  not  all,  Avere  exiilained  by  the  in-fiammatonj  process  either 
extending  tltroiif/li  or  irausmiffinci  its  toxins  through  the  thin 
bone  Avails  to  the  adjacent  nerve-trunks  because  I  had  proved 
that  cocaine  readily  passed  through  from  the  sphenoid  sinus  ta 


122  HEADACHES    AND    EYE    DISORDERS    OF    NASAL   ORIGIN 

the  nerve-trunhs.  But  witliiii  tlie  past  few  years,  as  a  result  of 
a  much  wider  clinical  experience,  I  have  come  to  feel  that  there 
are  probably  several  factors  contributing  to  the  clinical  pic- 
ture, those  being  two  of  them,  and  that  a  third  and  probably 
much  more  serious  one  is  the  bone  change  in  the  hyperplastic 
process  with  or  without  periostitis.  The  bone  change,  how- 
ever, required  the  proof  which  Dr.  AVright  has  supplied.  It 
would  seem  that  such  material  ought  to  be  obtainable  post- 
mortem, but  so  far  that  has  not  been  my  experience.  My  ideas 
therefore  have  of  necessity  been  formed  bj^  the  association  of 
some  facts  with  an  inductive  philosophy.  In  this  connection  it 
might  l)e  argued  that  the  condition  of  the  anterior  wall  of  the 
sphenoid  cell  (which  must  include  its  post-ethmoidal  face)  is 
not  a  criterion  for  the  remaining  part  of  the  body,  and  that 
conclusions  drawn  from  that  material  dare  not  be  generalized 
for  that  district.  Holmes'  nasopharyngoscope  is  an  aid  which 
permits  of  much  conclusive  ol)servation.  By  it  we  find  that  the 
hyperplastic  process  is  not  always  uniformly  distributed  within 
the  cell.  It  may  be  distributed  irregularly  but  is  usually  more 
marked  in  the  lower  half  of  the  cell. 

Hyperplastic  anterior  ethmoiditis  may  sometimes  precede 
a  like  change  in  the  post-ethmoidal-sphenoidal  district;  and  it 
was  from  such  cases  that  I  began  to  form  the  ideas  embodied 
in  this  text.  I  have  observed  some  of  them  for  nineteen  years. 
The  first  clinical  effect  in  such  a  case  is  the  closure  of  the 
frontal  sinus,  the  outlet  of  which,  aside  from  being  in  the  dis- 
trict where  the  process  so  readily  begins  because  of  the  direct 
blast  of  inspired  air  with  its  dust  and  bacteria,  lends  itself 
easily  to  clinical  manifestations  because  of  its  being  narrow 
usually  at  some  point  if  not  in  much  of  its  length;  and  therefore 
easily  closed.  Also  the  fact  pointed  out  by  TJffenorde^^  that 
the  submucous  connective  tissue  on  the  lateral  aspect  of  the 
middle  turbinate  and  ethmoidal  wall  is  loose,  readily  contrib- 
utes to  the  clinical  picture.  These  facts  give  rise  to  the  (non- 
suppurative) cases  which  Ewing  and  I  described  in  1900."  A 
part  of  the  air  within  the  cell  is  then  absorbed,  resulting  in  a 
negative  pressure  and  headache  accompanied  by  Ewing 's  sign 
(a  tender  point  at  the  upper  inner  front  of  the  orbit)  and 
asthenopia.     The  closure  may  also  he  l)rought  about  bv  other 


HYPERPLASTIC    SPHEXOIDITIS  123 

causes,  irrelevant  to  the  arg'iiment  hei'e,  a  detailed  enumeration 
of  which  with  differential  diagnosis  may  be  found  in  Chapter 
I.  The  pathological  state  bearing  upon  the  questions  here  in 
hand,  is  that  where  the  tissues  of  the  middle  meatus  become 
hyperplastic.  In  these  cases  the  membrane  readily  becomes 
edematous,  and  coryzas  make  polyps,  which  in  the  early  his- 
tory of  the  case  disappear  with  the  subsidence  of  the  acute  con- 
ditions ;  later  as  the  bone  becomes  more  hyperplastic  the  polyps 
remain  permanent.  It  has  been  my  habit  to  remove  the  middle 
turbinate  in  such  cases  by  an  incision  placed  about  2  mm,  below 
the  cribriform  plate.  This  gives,  in  usual  skulls,  a  funnel-shaped 
outlet  to  the  frontal  sinus,  apex  down,  made  by  the  uncinate 
process  in  front  and  the  ethmoid  bulla  behind  and  below,  the 
lower  part  being  the  hiatus  semilunaris,  measuring  normally 

1  to  2  mm.,  expanding  to  5  nun.  above,  anteroposteriorly,  and 

2  to  4  mm.,  laterally.  These  anatomical  details  are  elaborated  in 
Chapter  I.  Tlie  immediate  result  of  such  surgery  is  a  wide 
opening  of  the  frontal  sinus  into  the  nose  and  a  cessation  of 
all  symptoms  for  five  to  ten  years  (approximately).  The  pa- 
tient then  returns  for  treatment  at  the  time  of  a  coryza,  be- 
cause of  slight  headache  and  asthenoj^ia,  which  he  is  anxious 
about  from  previous  experience.  The  rhinologist  finds  the  out- 
let or  inlet  of  the  frontal  closed,  but  as  the  swollen  membrane 
shrinks  he  finds  that  the  symptoms  subside  and  that  the  outlet 
or  inlet  is  then  open,  but  smaller  than  it  ivas.  As  the  3'ears 
pass  he  finds  that  the  uncinate  thickens  a  little,  l)ut  that  the 
bulla  enlarges  more  and  the  outlet  or  inlet  of  the  frontal  be- 
comes smaller  and  finally  closes  ayain  and  the  oryincd  head- 
ache, etc.,  syndrome  is  re-established  ivithoiit  pus.  The  tis- 
sues from  such  cases  were  examined  by  Dr.  AVright  and  found 
to  show  the  changes  of  hyperplastic  ethmoiditis.  The  picture 
in  the  nose  shows  the  macroscopic  changes  to  correspond  and 
to  be  extending  backward;  and  later  (without  pus)  the  pain  of 
maxillary  and  Vidian  nerve  involvement:  that  is,  pain  around 
the  eye  and  in  the  upper  jaw  and  temple;  with  pain  in  the 
occiput  and  neck,  etc.,  is  added  as  the  process  in  the  bone  ex- 
tends backward;  and  polyps  begin  to  form  above  the  middle 
turbinate  line  at  the  time  of  a  coryza.  At  first  they  disappear 
with  recoverv  from  the  coryza;  later  they  become  permanent. 


124  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

In  the  progress  (development)  of  the  bone  disorder  hackivard^ 
the  maxillary  and  Vidian  headaches  appear  only  at  the  time 
of  coryza.  Later,  however,  they  recnr  at  longer  or  shorter 
intervals  in  more  or  less  severity  ivithout  visible  local  changes 
and  continne  to  do  so  iu definitely  with  the  neurologist's  diag- 
nosis ''migraine.''  (I  have  seen  such  headaclies  of  forty  years' 
standing  very  greatly  relieved  by  the  sphenoidal  operation. 
They  cannot  ])e  cured  by  operation  if  the  pathologic  mechanism 
be  correct  in  its  idea.)  The  same  clinical  picture  is  produced 
by  irritation  of  the  nasal  ganglion,  but  this  may  be  differen- 
tiated by  the  fact  tliat  the  nasal  ganglion  pain  can  be  stopped 
by  cocainization  of  tlie  ganglion,  whereas  the  pain  made  by  the 
sphenoid  in  the  nerve-trunks,  central  to  this,  cannot  be  stopped 
that  Avay.     (See  Chapter  II.) 

Optic  nerve  disorders  arise  ofteji,  secondary  to  hyperplas- 
tic bone  change  of  the  spheno-post-ethmoidal  district.  A  large 
percentage  are  preceded  by  those  headaches — often  for  many 
years.  In  some  cases  there  is  a  slow  encroachment  upon  the 
optic  nerve,  as  shown  l)y  slight  swelling  of  the  margin  of  the 
disc,  which  increases  slowdy  with  gradually  failing  vision.  This 
may  be  a  process  of  years.  Adamlvowitz^  found  that  slow  com- 
pression of  nerves  destroys  function  sloAvly.  In  other  cases 
the  eye  l)ecomes  quickly  blind  with  or  without  changes  in  the 
disc.  Some  cases  have  a  transitory  amblyopia.  Some  show 
muscle  im])alance,  prol)al)ly  because  of  discomfort  arising  from 
the  attachment  to  inflamed  bone  at  the  apex  of  the  orbit.  Some 
show  hyperaesthesia  and  hypalgesia  over  the  maxillary  dis- 
tribution. 

The  explanation  of  the  headaches  and  optic  disorders  in 
such  cases,  I  believe,  is  hyperplastic  bone  process  and  that  its 
mode  of  operation  is  to  narroiv  the  hone  canals  through  which 
the  respective  nerves  pass ;  i.  e.,  the  optic  canal  with  the  optic 
nerve,  the  foramen  rotundum  transmitting  the  maxillary,  the 
Vidian  canal  witli  the  Vidian  nerve.  The  foramen  ovale  with 
the  mandibular  nerve  only  rarely  comes  into  these  considera- 
tions because  it  is  usually  far  enough  removed  from  the  sphe- 
noid cell  to  be  exempt  as  a  clinical  factor.  (It  does,  however, 
sometimes  become  a  part  of  these  pictures.)  This  seems  to 
me  a  reasonable  deduction  from  Dr.  Wright's  findings  in  the 


HYPERPLASTIC    SPHEXOIDITIS  125 

wall  of  the  splieiioicl  in  eon  junction  with  intra  sphenoidal  ( pha- 
ryngoscope)  observation,  together  with  the  easily  seen  behavior 
of  the  process  on  the  lateral  wall  anteriorly,  where  the  fron- 
tal outlet  may  l^e  seen  narrowing  from  year  to  year.  It  may 
liere  be  nrged  that  the  intranasal  observation  was  made  in  a 
part  exposed  to  the  atmospheric  air  and  that  tlie  foramina  and 
canals  mentioned  are  not  so  exposed;  and  that  the  frontal  out- 
let being  empty  offers  no  resistance  to  encroachment  whereas 
the  foramina  and  canals  are  snugly  filled  and  ^\ould  offer 
some,  if  not  considerable  resistance;  and  that  the  osteoblasts 
-are  active  only  on  convexities.  I  have,  however,  seen  the  unci- 
nate process  become  markedly  thickened  and  enlarged  in  its 
concavity  in  the  progress  of  hyperplastic  anterior  ethmoiditis 
(also  observed  by  Ufienorde^^).  And  it  may  be  urged  tliat  the 
lesion  in  the  foramina  and  canals  is  probalily  a  periostitis, 
which  is,  judging  from  the  removed  bone,  probal)ly  true  in 
■some  cases,  but  not  all,  l)y  any  means ;  whereas  the  hyperplas- 
tic bone  change  was  constant  for  tliis  class  of  cases  and  ex- 
tended through  the  depths  of  the  tissues.  In  otlier  words,  it  was 
not  limited  to  the  part  exposed  to  the  air  and  was  irregularly 
accompanied  by  periostitis.  Dr.  Wright  and  I  believe  that  tlie 
process  begins  as  a  surface  tissue  change,  and  proceeds  to  the 
periosteal  layers  and  bone.  But  the  sections  show  that  the  sur- 
face and  periosteum  may  recover  and  the  deeper  changes  go  on. 

The  canals  in  the  skulls  of  present-day  children  have  often 
•seemed  to  me  larger  than  those  of  the  present-day  adult. 

This,  however,  is  a  difficult  point  to  determine  and  ma^- 
very  readily  I)e  only  apparent  and  not  real.  In  truth  it  would 
seem  that  in  the  National  Museum,  AVasliington,  the  privileges 
of  which  were  kindl}^  permitted  by  Dr.  Ales  Hrdlicka,  the  di- 
rector, in  specimens  of  tlie  skulls  of  aboriginal  American  In- 
dians this  is  probably  not  the  fact.  Professor  Arthur  Kieth's 
observations'^^  argue  against  anatomical  cliange  being  possible 
in  a  few  thousand  years.  Larger  canals  would  explain  why 
these  headaches  and  optic  nerve  troubles  do  not  begin  more  often 
in  childhood.  I  have,  however,  seen  the  headaches  at  the  age 
of  three  and  seven  years  and  the  eye  troulole  at  six  years. 
It  is  easily  conceivable  that  a  small  space  around  each  nerve 
is  left  more  or  less  filled  with  fat  or  loose  connective  tissue. 


126  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

This  tissue  would  be  easily  compressible  in  the  foramina  and 
canals  and  might  allow  for  or  accommodate  a  congestion  rising 
from  whatever  of  many  causes ;  e.  g.,  a  digestive  or  other  sys- 
temic toxemia  or  the  mechanical  gravity  congestion  produced 
by  making  the  head  the  lowermost  instead  of  the  uppermost 
part  of  the  body  (in  other  words,  when  the  head  is  turned 
downward  in  any  considerable  degree).  If  the  narrowing  of 
the  canal  or  foramen  is  merely  enough  to  take  u^d  this  small 
space,  it  will,  it  seems  to  me,  place  that  nerve  in  a  ^aIlnerable 
position,  which  explains  some  of  the  phenomena  of  these  cases, 
namely,  pain  esta])lished  instantly  by  bending  the  head  down 
or  by  coughing  or  sneezing  in  which  the  j)eripheral  blood-pres- 
sure is  suddenly  raised,  and  sudden  transitor)^  amblyopia.  Fur- 
ther encroachment  on  their  calibre  would  explain  the  slow  pro- 
gressive optic  nerve  cases  and  the  more  protracted  severe  head- 
aches. 

If  now  it  be  conceded  that  hyperplastic  bone  process  can 
and  does  narrow  the  bony  foramina  and  canals  adjacent  to  the 
sphenoid  sinus,  and  that  the  narrowing  is  the  cause  of  the  pain 
in  all  the  contained  nerves  except  the  optic;  and  that  the  optic 
also  suffers  according  to  the  degree  and  rapidity  of  the  patho- 
logical process — we  have  also  the  explanation  of  why  maxillary 
and  Vidian  pains  are  so  very  much  the  more  frequent  symp- 
toms, because  the  lower  part  of  the  sphenoid  sinus  where  the 
canals  run  which  transmit  those  nerves  is  most  often  affected, 
and  the  factor  of  secretions  and  their  toxicity  plays  here  in 
addition  to  what  may  be  the  process  in  the  bone.  They  re- 
main in  the  lower  part.  Next  in  order  of  frequency  is  affec- 
tion of  the  optic  nerve.  That  this,  however,  is  less  frequent 
than  the  maxillary  and  Vidian  lesions  is  probably  likewise  a 
matter  of  drainage,  it  being  higher  and  forward  in  the  sinus. 
The  wall  of  the  optic  canal  cannot  as  a  rule  be  submerged  in 
secretion  in  any  position  in  which  the  head  may  be  placed 
unless  the  ostium  sphenoidale  be  closed.  In  the  erect  posture 
the  sinus  will  overflow  ere  this  is  reached.  The  only  positions 
of  the  usual  skull  making  the  optic  canal  dependent  is  face 
downward,  and  that  again  would  fail  because  the  ostium  Avould 
be  placed  below  and  drain  the  cavity,  or  possibly  lying  on  that 
side  of  the  head ;  i.  e.,  left  side  for  left  optic  canal,  with  con- 


HYPERPLASTIC    SPHENOIDITIS  127 

siderable  secretion  contained  in  the  sinns.  Loel)*^  has  shown 
that  the  ostium  is  usually  midway  between  the  roof  and  floor 
of  the  sinus. 

The  optic  canal  would  seem  to  be  almost  of  necessity  a 
later  involvement,  by  bone  extension ;  or  localized  inflanima- 
tori)  areas  from  a  coryza. 

In  contradistinction  to  the  clinical  lesions  of  these  nerves 
in  bony  confines,  are  such  lesions  of  the  nerves  in  the  soft 
(loose)  confines  of  the  sphenoidal  fissure;  to  wit,  the  oculo- 
motor, trochlear,  ophthalmic,  and  a])ducent,  although  these 
nerves  are  in  contact  with  the  bone  for  a  longer  or  shorter 
distance  as  they  pass  through  the  sphenoidal  fissure  into  the 
orbit  or  the  clivus  of  Blumenbach.  The  bone  here  may  be  hol- 
lowed (often)  by  the  sphenoid  sinus  extending  into  the  great 
wing  or  even  ])y  the  frontal  extending  backward  into  the  les- 
ser wing  (rare)  or  by  sphenoidal  or  ethmoidal  cells  projected 
into  that  district.  In  my  experience  a  supraorbital  nerve  pain 
of  sphenoidal  origin  is  rare.  Ophthalmic  nerve  contact  with 
a  thin  walled  sinus,  hoAvever,  is  also  rare.  Pain  in  the  brow- 
is  frequent  and  may  arise  from  a  number  of  causes ;  e.  g.,  fron- 
tal sinus  vacuum  or  empyema,  or  maxillary  irritation  in  the 
sphenoid,  and  these  must  be  very  carefully  differentiated. 
Supraorbital  neuralgia,  however,  of  systemic  toxic  origin  is 
very  frequent.  A  lesion  of  the  trochlear  is  also  very  rare, 
according  to  my  experience  and  that  of  my  ophthalmological  as- 
sociates. Sphenoidal  lesions  of  the  oculomotor  and  abducens 
are  seen  oftener  l^ecause  of  their  arrangement  in  the  sphe- 
noidal fissure  (the  sixtli  is  exposed  on  the  clivus  of  Blumen- 
bach and  the  sixth  and  third  come  into  relation  with  the  wall 
of  the  sinus  as  soon  as  it  is  prolonged  into  the  great  wing,  the 
fourth  is  more  protected).  These  lesions  are  seen,  however, 
much  less  often  than  those  of  the  optic  and  infinitely  less  often 
than  the  maxillary  and  Vidian  lesions.  It  is  a  fact  that  the 
nerves  in  soft  confines  are  not  as  often  exposed  to  the  sphenoid 
sinus  as  those  in  the  bone  confines.  But  this,  to  my  mind,  ex- 
plains only  a  small  part  of  the  great  statistical  differences, 
i.  e.,  the  very  frecpient  involvement  of  those  in  the  bone  con- 
fines and  the  very  infrequent  invoh'ement  of  those  in  the  soft 
confines.     And  in  this  connection  I  emphasize  again  that  nar- 


128  HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN 

rowing  of  their  confines  is  the  probable  prominent  part  of  the 
lesion.  ^Vere  the  simple  inflammatory  lorocess  in  the  membra- 
nous lining-  of  the  sinus  responsible  for  the  clinical  pictures  by 
transmission  of  its  toxins  through  the  lione,  or  AA'ere  a  peri- 
ostitis of  the  foramina  and  the  sphenoidal  fissure,  or  Avere  the 
lesion  a  neuritis  from  continuity,  to  l)lame,  then  in  all  reason- 
able probability  would  the  oculomotor,  trochlear,  ophthalmic 
and  abducent  take  part  in  these  pictures  more  often.  I  believe 
this  because  of  my  cocaine  experiments  (see  page  112).  In  some 
skulls  the  entire  trigeminus  may  be  paralyzed  by  painting  the 
sphenoid  sinus  with  cocaine  solution,  with  great  confusion  in 
the  eye  which  the  patient  cannot  descri])e.  The  sphenoidal 
sinus  enlarges  until  it  comes  in  close  relation  with  the  foramen 
rotundum  often  as  early  as  the  third  year  of  life  and  by  the 
seventh  year  often  reaches  to  the  Vidian  canal.  This  seems  to 
me  to  be  the  anatomical  explanation  of  these  cases  in  childhood. 
They  are,  however,  rarer  in  childhood,  as  may  be  expected  if 
\ye  accept  the  theory  of  narrowing  of  the  canals. 

Dr.  AYright  believes  thaj.  some  of  the  pain  in  these  cases 
must  be  made  by  a  periostitis  in  the  nasal  fossae  just  as  such  a 
lesion  on  the  shaft  of  the  tibia  causes  pain. 

Post-ethmoidal-sphenoidal  inflammation  in  the  young  often 
takes  on  the  hyperplastic  bone  process  evidenced  by  thickening, 
polyps  and  general  edema.  In  children  it  is  often  the  cause  of 
frequent  coryza  with  paroxysmal  sneezing,  asthma,  bronchitis 
and  fever.  I  believe  these  symptoms,  not  fever,  are  l)rought 
al^out  as  a  sympathetic  nerve  manifestation  from  the  nasal  gan- 
glion. Pediatricians  often  report  this  syndrome  as  the  result 
of  other  causes  without  the  nose  having  been  excluded  as  a 
possible  factor. 

An  index  to  the  hyperplastic  process  seems  to  exist.  The 
degree  of  hyperplasia  of  the  plica  septi  seems  to  indicate  a  cor- 
responding degree  in  tlio  sphenoid,  explicable  probably  by  vir- 
tue of  the  fact  that  secretioii  from  the  sphenoid  descends  over 
the  plica  (usually)  whereas  that  from  the  post-ethmoid  passes 
over  the  end  of  the  turbinate.  The  secretion  is  often  serous. 
I  believe,  however,  it  is  distinctly  irritant.  This  would  seem  so 
from  its  effect  on  the  skin  of  the  tip  of  the  nose  and  the  lip. 


HYPERPLASTIC    SPHENOIDITIS  129 

The  middle  turbinate  in  general  is  not,  however,  an  index  of 
the  changes  in  the  'post-etlimoidal-splienoidjal  sinuses. 

Hyperplastic  sphenoiditis,  in  my  opinion,  is  the  explana- 
tion of  Avhy  the  treatment  of  nasal  ganglion  neuralgia  is  so 
often  disappointing.  The  diagnosis  may  seem  clear  inasmuch 
as  the  pain  complex  ma}^  be  controllable  from  the  nasal  gan- 
glion by  cocaine,  but  injection  of  the  ganglion  is  followed  by 
only  short  time  relief  because  the  irritation  continues.  The 
injection  of  the  ganglion  helps,  but  the  satisfactory  relief  of 
the  case  is  accomplished  only  after  the  hyperplastic  bone  proc- 
ess has  been  controlled.  This  happens  sometimes  as  a  result 
of  the  injection  but  at  other  times  reinjection  and  in  many,  a 
post-ethmoidal-sphenoidal  operation  with  after  treatment  are 
required.  Until  this  is  accomplished,  the  hyperplastic  bone 
process  may  keep  vq)  the  ganglion  irritation  indefinitely. 

The  best  post-operative  anatomical  results — 1  mean  by 
this,  that  the  result  has  remained  better,  for  a  longer  time,  i.  e., 
remained  less  altered  by  a  continuance  of  the  hyperplastic 
process,  according  to  my  observation — have  been  in  patients 
whose  general  bony  skulls  have  changed  least  from  year  to 
year.  These  patients  show  age  by  change  in  the  skin  rather 
than  of  feature. 

In  all  these  cases  a  slight  acute  process  added  to  the  ex- 
istent hyperplastic  process  brings  on  disaster  out  of  propor- 
tion to  the  acute  process., 

I  record  the  observations  of  Dr.  Wright  made  upon  the 
conclusion  of  the  examination  of  the  series  of  specimens : 

''As  a  result  of  the  observations  made  upon  Doctor  Slu- 
der's  specimens  and  as  the  result  of  the  conference  Avith  him  in 
which  he  has  detailed  the  history  of  each  case  in  connection 
with  the  pathological  findings,  one  may  say  in  a  general  way 
that  the  coincidence  of  inflammations  of  the  middle  turbinate 
with  inflammations  of  the  sphenoidal  sinus,  is  by  no  means  uni- 
versal, that  is,  in  some  of  the  cases  marked  involvement  of  the 
mucous  membrane  and  of  the  bony  structures  in  and  around 
the  sphenoidal  sinus  was  observed  while  the  middle  turbinate 
was  in  a  fairly  normal  condition,  and  the  same  is  true  in  a  re- 
verse sense. 

"I  have  been  especially  struck  in  examining  the  cases  to 


130  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

observe  that  the  vast  majority  of  specimens  submitted  to  me 
were  from  female  patients.  Doctor  Sluder  perhaj)s  can  go  more 
carefully  into  the  relative  proportion  of  these,  but  so  far  as  the 
slides  which  he  has  submitted  to  me  go,  it  is  quite  evident  that 
perhaps  three-quarters  of  them  are  from  females. 

"As  to  the  histological  findings,  again  it  may  be  said  that 
evidently  the  inflammation  of  the  upper  sinuses  of  the  nose  is 
a  very  frequent  occurrence  with  many  of  the  symptoms  of 
pain  in  and  about  the  nose  or  even  of  diffuse  headaches  appar- 
ently due  to  a  periostitis  Avith  a  local  cause.  Apx)arently,  pro- 
found changes  ma^^  occur  in  these  cases  in  the  mucous  mem- 
brane and  in  the  bone  without  serious  involvement  of  the  im- 
portant structures  with  which  Doctor  Sluder  has  so  long  been 
busy,  but  when  inflaimnatory  exudates  occur  in  such  a  way 
that  the  Vidian  nerve  and  the  second  division  of  the  fifth  are 
affected  b^^  the  pressure  of  inflammatory  exudates,  we  get 
periphery  manifestations  of  pain  in  the  loAver  part  of  the  head 
and  the  cervical  region  running  down  to  the  shoulder  which  is 
very  distressing  and  ol)stinate  and  ma^^  last  for  years.  Appar- 
ently, the  same  principle  may  be  applied  to  the  optic  nerve. 

"The  patient  may  have  had  inflammatory  conditions  of 
his  sphenoidal  sinus  for  many  years  before  serious  involvement 
of  the  optic  nerve  occurs.  When  it  does,  the  evidence  goes  to 
show  that  the  inflammatory  process  has  extended  to  the  neigh- 
borhood of  the  course  of  the  optic  nerve  from  the  upper  and 
outer  wall  of  the  sphenoidal  sinus  inducing  marked  functional 
disturbance  in  the  eye  or  even  complete  destruction  of  the  func- 
tion of  the  optic  nerve." 

Dr.  Wright's  observation  that  most  of  the  patients  Avere 
females  is  true  for  the  series  presented.  In  practice,  however, 
I  think  the  preponderance  of  females  over  males  is  much 
smaller,  if  they  be  not  almost  equally  divided.  In  an  epidemic 
of  post-nasal  infections  such  as  has  existed  in  St.  Louis  for 
three  years  (1912-1914  inclusive),  and  I  understand  has  ex- 
isted in  other  parts  of  the  United  States  also,  the  sexes  seemed 
to  me  to  be  equally  attacked.  The  females  seem  to  become 
chronic  sufferers  somewhat  oftener  than  the  males,  possibly 
because  their  bones  are  often  lighter,  which  means  that  the 
above  considered  nerve-trunks  have  less  protection. 


HYPERPLASTIC    SPHEXOJDITIS  131 

DIAGNOSIS 

The  clinical  diagnosis  of  hyperplastic  post-ethmoidal  sphe- 
noiditis  follows  the  same  general  rules  that  govern  the  anterior 
ethmoidal  region.  TJie  former  is,  however,  very  much  more  in- 
accessible and  mnst  1)e  illnminated  through  a  much  longer  and 
narrower  channel  v.hen  examined  from  the  throat.  Examina- 
tion from  the  front  of  the  nose  is  so  seldom  satisfactory  that 
it  cannot  be  relied  upon.  If  a  cadaver  be  examined  and  meas- 
ured it  will  be  found  that  from  the  post-nasal  glass  as  it  rests 
in  tlie  throat  to  the  upper  meatus  and  the  sphenoethmoidal 
recess  is,  in  a  full  sized  head,  a  distance  of  from  6  to  8  cm.  This 
illumination  must  be  supplied  by  reflection  from  a  glass  often 
as  small  as  1  cm.  in  diameter  and  be  projected  into  the  narrow 
olfactory  fissure.  It  therefore  recpiires  a  powerful  source  of 
light  to  be  sufficiently  illuminating  when  reduced  to  this  small 
pencil  at  that  distance.  These  points  may  appear  trite  but 
from  great  experience  with  the  patient  I  feel  that  they  cannot 
be  too  much  emphasized,  and  from  a  wide  experience  with 
rhinologists  of  all  degrees  of  professional  acumen,  I  feel  that 
the  intensity  and  quality  of  the  light  employed  for  these  pur- 
poses are  very  often  unsatisfactory  for  the  necessities  beset- 
ting this  district. 

The  one,  oldest  light,  all  powerful,  uniform,  white  and 
available  for  everyone  is  the  direct  sun.  "When  focused,  how- 
ever, by  the  concave  head  mirror  it  is  too  hot  to  be  borne  by 
the  patient.  It  must  therefore  be  used  with  the  head  mirror 
more  or  less  out  of  focus.  Moreover  the  direct  sun  on  a  clear 
day  focused  by  a  10  cm.  head  mirror  is  so  very  intense  that  it 
is  apt  to  obliterate  much  if  not  all  of  the  detail  of  the  picture 
and  so  defeat  its  own  special  ends.  Furthermore  the  brighter 
the  light,  the  more  evident  become  all  flaws  in  the  post-nasal 
glass  however  minute  (such  as  scratches  made  by  wiping), 
which  make  more  or  less  added  difficulties.  Using  the  head 
mirror  out  of  focus  therefore  serves  three  important  purposes. 
The  same  objects  are  attained  by  using  the  sun  shining  through 
thin  fleecy  clouds  or  something  giving  this  effect.  Among 
the  electric  lights  must  be  mentioned  an  arc  light  made  and  sold 
by  Ernst  Leitz  of  AVetzler,  Germanv.  under  tlie  name  of  ''Lil- 


132  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

liput  Arc  Lamp"  which  is  as  satisfactory  as  the  direct  sun, 
with  the  advantage  of  being  available  at  any  hour.  The  car- 
bons meet  at  a  right  angle  and  give  a  very  brilliant  white  light 
which  is  condensed  into  a  pencil  by  a  convex  lens.  When  this 
pencil  is  reflected  by  a  coucave  head  mirror  and  focused  it 
is  practically  indistinguishable  from  the  sun  but  not  quite  so 
brilliant  or  so  hot,  l)oth  of  which  points  are  advantageous.  It 
is  a  different  light  from  that  of  the  arc  lamp  in  common  use 
as  street  illumination.  In  burning,  a  little  white  smoke  is  given 
off  which  condenses  to  a  white  powder  suggesting  zinc  oxide, 
suggesting  that  the  carbons  had  been  impregnated  with  a  zinc 
salt  which  may  be  the  way  in  which  the  "white"  light  is  made. 
Leitz  declines  to  tell  the  process  of  manufacture.  No  incan- 
descent Iralb  light  that  I  know  of  is  anything  like  so  satisfac- 
tory as  the  sun  or  the  "Lilliput  Arc"  for  brilliancy  or  color. 
The  gas  lights  have  more  serious  faults,  namely,  less  brilliancy 
and  more  colors.  The  liglit  should  be  white  and  bright.  A 
yellow  or  red  color  to  the  light  interferes  with  the  correct  es- 
timate of  the  color  of  the  membrane  and  sometimes  the  thick- 
ness of  the  epithelium  in  the  i^arts  examined  and  a  green  or 
yellow  color  makes  the  recognition  of  small  amounts  of  thin 
greenish  or  yellowish  secretion  very  difficult  or  impossible. 
The  Argand  gas  lamp  is  quite  red  and  yellow  and  tlie  incan- 
descent gas  mantle  (AYelsbach  or  Aner's)  is  green  and  yellow 
and  of  far  too  little  brilliancy.  So  it  is  (to  my  mind)  the 
source  of  light  in  routine  use  by  rhinologists  at  present  is  usu- 
ally unsatisfactory  for  post-nasal  observation  although  I  rec- 
ognize that  for  anterior  rhinoscopy  tliey  answer  their  purposes. 
The  advantages  of  a  brilliant  white  light  have  been  recognized 
by  laryngolo gists  for  many  ^.ears.  Morell  McKenzie  in  The 
Laryngoscope,  third  edition,  described  the  oxyhydrogen  cal- 
cium light  and  I  saw  it  in  use  in  tlie  London  clinics  a  number 
of  years  ago.  The  calcium  light  is  perfect  but  more  trouble- 
some than  the  electric  arc.  The  importance  and  advantages  of 
bright  white  light  for  the  spheno-etlimoidal  district  have  not 
heretofore  been  emphasized.  One  other  source  of  light  and 
means  of  observation  should  be  mentioned,  namely,  Holmes' 
nasopharyngoscope.  Sometimes  it  is  of  the  utmost  help  by 
virtue  of  its  right  angle  vision  and  should  always  be  at  hand, 


HYPERPLASTIC    SPIIEXOIDITIS  133 

but  its  short  focus  and  iucauclescent  lamp  make  the  interpreta- 
tion of  its  picture  more  difficult  than  that  of  direct  vision  with 
strong  white  light. 

Another  item  that  may  seem  supererogatory  is  a  descrip- 
tion of  the  normal  post-ethmoidal-sphenoidal  district.  No  clear 
description,  however,  such  as  will  answer  my  purposes,  exists 
so  far  as  I  knoAv. 

The  posterior  end  of  the  middle  turbinate  should  be  con- 
sidered the  lower  boundary  of  this  region.  The  posterior  mar- 
gin of  the  vomer  bears  the  plica  septi.  In  the  effort  to  describe 
the  normal  of  this  region,  emphasis  should  be  laid  on  the  color, 
thickness  and  translucency  of  the  membrane  of  the  olfactory 
fissure  and  the  size  and  character  of  the  posterior  tip  of  the 
middle  turbinate  and  the  plica  septi. 

The  color  of  the  normal  inembrane  is  pink  and  it  fits  close 
to  the  bone.  It  gives  the  impression  of  thin  pink  silk  velvet. 
The  epithelium  is  smooth  and  transparent  and  the  effect  is 
given  that  the  membrane  is  translucent.  It  appears  moist  but 
not  wet.  If  it  is  Avet  it  will  glisten.  (The  degree  of  moisture 
here  is,  to  my  mind,  an  important  item.)  No  vessels  are  rec- 
ognizable clinically.  The  middle  turbinate  tip  is  smooth  and 
pink  but  gives  the  impression  that  the  membrane  is  less  closely 
applied  to  the  underlying  l)one.  The  plica  septi  is  only  slightly 
developed  and  is  of  pearl  pink  appearance,  that  is  to  say,  it  is 
slightly  less  translucent  than  the  surrounding  membrane.  Such 
a  picture  is  not  seen  in  the  routine  of  a  rhinologist's  practice 
as  a  rule.  Patients  who  consult  him  have  had  some  disturb- 
ance in  this  district  in  the  great  majority  of  instances.  He 
can,  however,  familiarize  himself  with  it  by  observation  on  chil- 
dren suitable  for  the  purpose  or  on  adults  who  have  been  free 
of  nasal  disorders  and  who  are  not  "subject  to  headache  and 
stiff'  neck."  I  emphasize  this  point  because  such  patients  are 
frequently  unconscious  of  an  existing  nasal  lesion  as  their 
causes.  Another  district  which  furnishes  a  membrane  similar 
or  identical  is  the  septum  in  the  lower  anterior  half  but  Avell 
back  of  the  vestibule.  The  membrane  here  is  not  apt  to  show 
hyperplastic  changes  until  the  remaining  nose  is  markedly  in- 
volved by  that  process. 

An  acute  inflammation  in  this  district  causes  the  membrane 


134  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

to  swell  and  become  darker  red  and  more  moist — wet.  (Some- 
times it  is  found  that  the  appearance  of  acute  inflammation  is 
not  an  acute  state,  hut  is  present  as  a  chronic  state  and  some- 
times it  is  present  throughout  the  nose.)  Pus  may  or  may  not 
accompany  it.  It  does  not  cause  the  vessels  to  show  or  the 
epithelium  to  l)ecome  opaque  or  rough.  When,  however,  it  is 
oft  repeated,  some  swelling  remains  permanent  and  some  small 
vessels  become  visible  and  a  quality  of  opacity  is  added  Avliich 
is  from  thickening  and  clouding  of  the  epithelium.  Moisture 
or  pus  may  or  may  not  always  be  present.  The  surface  ap- 
pears more  or  less  roughened.  Swelling  of  an  edematous  na- 
ture may  l)e  present  but  it  is  much  less  likely  than  in  the 
middle  meatus  in  front,  under  similar  conditions. 

Another  change  in  the  membrane  of  this  district  which 
should  be  carefully  observed  is  a  velvet-like  thickening  with- 
out much  if  any  change  in  coloi-  or  moisture  and  ^\itliout  the 
appearance  of  macroscopic  blood  vessels.  Slight  roughening 
of  the  surface  may  be  discernible  without  opacity.  It  reminds 
one  of  the  "lymx^hoid  enlargement"  of  the  tonsil  in  contra- 
distinction to  the  "inflaimnatory  enlargement." 

All  changes  in  these  parts  should  be  carefully  noted  be- 
cause a  very  slight  surface  change  is  often  accompanied  by 
much  more  advanced  and  serious  change  in  the  deeper  parts  as 
is  often  shown  by  the  finding  of  polyps  within  the  cells  at  the 
time  of  operation,  no  evidence  of  which  was  previously  recog- 
nizable. And  furthermore,  patches  of  inflammation  may  often 
be  found  with  the  pharyngoscope  within  the  cells  which  are 
very  pernicious  and  disastrous  according  to  their  location ;  e.  g., 
upon  the  optic  canal.  These  patches  are  often  much  more 
marked  than  the  changes  in  the  parts  exposed  for  observation 
prior  to  the  opening  of  the  cells. 

For  these  reasons  I  feel  that  the  normal  should  be  clearly 
fixed  in  the  rhinologist's  mind  and  all  changes  departing  from 
it,  however  slight,  should  be  most  carefully  considered.  There 
is  a  tendency  at  present  among  rhinologists  to  advocate  a  post- 
ethmoidal-sphenoidal  operation  in  cases  of  optic  neuritis  even 
though-  the  sphenoid  is  normal.  I  believe  close  attention  to 
these  points  will  show  that  very  few  if  any  of  these  cases  are 
normal.    Furthermore  I  do  not  l)elieve  that  the  post-ethmoidal- 


HYPERPLASTIC    SPHEXOIDITIS  135 

sphenoidal  operation  is  free  of  danger  in  the  hands  of  any 
rhinologist.  The  most  experienced  rhinologist  may  get  lost  in 
this  region  at  times.  I  have  seen  the  eye  which  it  was  intended 
to  save,  lost  for  the  vision  it  had  at  the  time  of  operation,  and 
Harmon  Smith^'^  also  has  reported  such  disaster.  In  private 
conversation  with  rhinologists  I  have  learned  of  death  follow- 
ing a  nnmber  of  these  operations.  Simple  opening  of  the  sphe- 
noid from  its  natural  opening  do^^^lwards  is  as  nearly  free  of 
danger  as  surgery  may  well  he,  but  that  is  utterly  insufficient 
in  many  cases,  as  will  be  at  once  seen  from  an  inspection  of 
almost  an}^  set  of  a  dozen  specim.ens.  Sometimes  the  sphe- 
noid sinus  makes  the  inner  loart  of  the  optic  canal  and  some- 
times the  post-ethmoidal  makes  it;  and  there  is  no  Avay  to  tell 
in  the  patient  at  the  time  of  operation  which  it  is.  Therefore 
the  sure  practice  is  to  do  the  combined  operation. 

The  distribution  of  the  hyperplastic  process  here  is  of 
great  interest,  and  various.  Sometimes  it  is  an  extension  back- 
ward of  an  easily  recognizal)le  hyperplastic  anterior  ethmoid- 
itis*^"  manifest  by  enlargement  of  the  soft  parts  and  bone  of  the 
middle  turbinate  with  edema  and  polyps  in  the  middle  meatus 
or  sometimes  extension  backward  of  a  general  hyperplastic 
rhinitis.  But  these  are  to  my  mind  by  no  means  necessary 
forerunners.  Frequently  I  have  seen  hyperplastic  post-eth- 
moidal splienoiditis  develop  in  adults  who  had  l)een  my  patients 
from  early  childhood  and  who  to  my  personal  knowledge  had 
never  had  a  clinically  recognizable  affection  of  any  of  their 
paranasal  cells,  and  did  not  have  a  general  hyperplastic  rhi- 
nitis. In  these  patients  it  began  as  the  primary,  and  w^as  the 
only  sinus  involvement.  It  Avas  the  result  of  repeated  infec- 
tion of  this  district  alone.  It  furthermore  is  capable  of  other 
niceties  of  distribution.  Later  it  develops  more  markedly  as 
a  post-ethmoiditis  or  a  sphenoiditis.  It  seems  to  me  from  close 
observation  that  a  post-ethmoiditis  in  time  brings  about  a 
hyperplasia  of  the  posterior  tip  of  the  middle  turbinate,  and 
that  a  sphenoiditis  lilvewise  produces  a  hyperplasia  of  the  plica 
septi.  Explanation  of  these  phenomena  seems  to  me  to  lie  in 
the  fact  that  the  thin  serous  secretion  Avhich  usually  accom- 
panies this  process  is  discharged  from  the  post-ethmoidal  out- 

*Uffenorde  has  given  a  careful  description  of  this  anterior  picture  clinically  and  anatom- 
ically  to  which  the  reader  is   earnestly   referred. 


136  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

let  over  the  posterior  tip  of  the  turbinate,  whereas  the  thin 
secretion  from  the  spheiioid  in  the  sphenoethmoidal  recess  is 
usually  found  over  the  plica  septi  vvdiile  the  head  is  erect.  I 
have  proved  these  facts  on  the  cadaver.  This  secretion  is  in 
all  likelihood  irritant  if  the  effects  of  nasal  serous  discharge  on 
the  lip  may  be  taken  as  a  criterion. 

I  should  like  particularly  to  call  attention  to  a  hyperplas- 
tic inflammation  of  the  posterior  tip  of  the  middle  turbinate 
and  the  sphenopalatine  foramen  district,  for  the  reason  that 
this  lesion  has  so  often  been  the  accompaniment  of  chorioiditis 
with  clouding  of  the  vitreous,  iritis  and  hemorrhage  into  the 
vitreous  and  anterior  chamber.  I  do  not  recall  that  this  has  been 
associated  with  optic  neuritis.  Dr.  Wright  observed  that  the 
vessels  in  the  material  removed  from  these  cases  showed  more 
involvement  than  the  specimens  removed  from  the  headache  or 
the  optic  cases  with  less  bone  involvement. 

Polyp  formation  ina}^  accompany  hyperplastic  post-eth- 
moidal  sphenoiditis  and  show  in  the  olfactory  fissure  constantly 
or  only  at  the  time  of  a  cor^-za  to  disappear  with  recovery 
from  the  coryza.  These,  however,  are  the  less  frequent 
cases.  The  jDrobe  may  recognize  the  more  advanced  degrees 
of  thickening. 

Post-ethmoidal-sphenoidal  suppuration  is  readily  recogniz- 
able if  the  pus  is  thick  and  adherent  so  that  it  remains  at  the 
point  of  entrance  into  the  nose;  and  is  at  all  profuse.  As  the 
case  begins  to  recover  and  the  secretion  becom.es  less  and  thin- 
ner it  is  not  always  so  easily  recognizable.  This  is  true  for 
several  reasons.  Firstly,  thin  secretion  easily  descends  from 
its  point  of  entrance  into  the  nose  and  is  not  readily  found  at 
that  point,  as  is  thick  adhering  jnis.  Secondly,  the  outlets  of 
the  post-ethmoid  and  sphenoid  cells  are  so  frequently  not  to 
be  seen  by  any  method  of  inspection  that  unless  the  pus  is  ad- 
herent enough  to  accumulate  at  those  points  it  will  not  be 
found.  In  a  narrow  nose  secretion  from  tlie  post-ethmoid,  in 
the  erect  or  reclining  posture  flows  over  the  middle  turbinate 
at  a  point  which  makes  it  very  difficult  or  impossible  to  recog- 
nize by  any  of  our  present  means  of  investigation.  In  a  wide 
nose  this  is  easily  seen  by  posterior  rhinoscopy,  sometimes  by 
Holmes'  pharyngoscope.     Some  of  the  secretion  passes  do\\ai- 


HYPERPLASTIC    SPHEXOIDITIS  137 

ward  and  backward  over  the  posterior  tip  of  the  turbinate  and 
Avonld  be  easily  recognized  if  it  remained  there,  bnt  in  small  and 
medium  sized  pharvnges  the  soft  palate  rises  in  s^^'allowing, 
and  certainly  in  gagging  (which  frecpiently  happens  in  the  ex- 
amination) to  a  height  that  wipes  it  awa^^  from  the  tip.  I  have 
proved  this  repeatedly.  It  is  necessary  therefore  to  recognize 
the  secretion  anterior  to  the  choanal  plane.  In  many  instances 
this  is  very  difficult  or  impossible ;  to  wit,  in  sucli  cases  as  have 
small  choanal  outlets  Avhicli  are  placed  rather  high  compared 
to  the  level  at  which  the  post-nasal  glass  nmst  rest.  It  will 
therefore  be  recognized  that  my  argument  is  that  a  x)ost-eth- 
moidal  sphenoiditis  may  exist  and  pour  in  the  nose  a  thin  secre- 
tion which  cannot  be  recognized  at  the  points  of  entrance  into 
the  nose.  Secretion  from  these  parts,  when  from  a  process  of 
long  standing  eventually  becomes  serous,  transparent  and  col- 
orless. When  from  a  process  of  more  recent  origin  it  is  sero- 
purulent,  not  unlike  thin  cow's  milk  in  color  and  thickness. 
The  picture  may  be  reproduced  in  great  verisimilitude  by  the 
instillation  of  a  fevr  drops  of  thin  cow's  milk  into  the  olfactory 
fissure.  Such  an  experiment  will  also  prove  the  short  time  such 
a  fluid  remains  recognizable.  In  from  three  to  five  minutes 
it  will  have  disappeared:  and  also,  in  a  small  pharynx  the 
Aviping  effect  of  the  palate  ma>'  easily  be  seen. 

Very  seldom  is  to  be  seen  a  stream  of  pus  coming  from 
the  sphenoid  and  descending  from  the  sphenoethmoidal  process 
over  the  posterior  pharyngeal  wall  to  descend  before  it.  This 
happens  only  in  large  pharynges  where  the  soft  palate  is  too 
short  to  reach  up  to  wipe  it  off.  Were  it  not  for  the  wiping 
effect  of  the  palate,  this  would  be  a  frequent  picture. 

As  the  inflannnatory  process  continues  the  secretion  loses 
all  purulent  character,  and  the  hyperplasia  begins.  Hyper- 
plastic post-ethmoidal  sphenoiditis  is  usually  accompanied  by 
a  scant  serous  secretion  but  by  no  means  is  tliis  always  true, 
just  as  tlie  same  process  in  the  middle  meatus  is  usually  accom- 
panied by  a  little  serous  secretion  but  not  always.  And  some- 
times the  serum  may  be  profuse,  but  I  have  uniformly  found 
this  to  be  from  the  process  localized  or  at  least  well  marked 
in  the  membrane  over  the  sphenopalatine  foramen;  that  is,  just 
posterior  to  the  tip  of  the  middle  turbinate.     The  nasal  gan- 


138  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN     ■ 

glion  is  immediately  beneath  this  membrane.  I  have  construed 
and  described-*  these  cases  as  manifestations  on  the  part  of 
the  sjanpathetic  autonomic  elements  of  the  nasal  ganglion,  and 
not  the  result  of  a  liyperplastic  process  in  the  general  expanse 
of  the  nose.  Treatment  of  the  ganglion  will  stop  the  profuse 
serous  secretion  but  will  not  stop  the  hyperplastic  process. 

Not  infrequently  it  is  found  that  secretion  of  any  kind  is 
totally  absent.  The  membrane  is  dry.  But  with  secretion  or 
Avithout,  under  the  microscope  the  lesion  is  the  same.  So  it  is 
therefore  necessary  to  recognize  the  changes  in  the  membrane, 
irrelevant  to  secretion.  This  is  done  by  translating  the  color, 
thickness,  translucency  of  the  epithelium  and  membrane,  and 
vascularity,  which  are  the  points  I  emphasized  in  the  descrip- 
tion of  the  normal.  A  typical  hyperplastic  picture  shows  some 
increase  in  redness  with  more  or  less  thickening  of  the  mem- 
brane and  epithelium.  The  epithelium  may  be  thickened  and 
rest  on  a  membrane  which  is  not  thicker  than  normal  or  the 
meml)rane  may  be  thickened  and  covered  by  epitlielium  which 
is  normal.  The  vascularity  is  increased,  manifested  by  the 
presence  of  macroscopic  vessels,  especially  radiating  from  ^he 
sphenopalatine  foramen.  In  addition  to  this  picture  exists  one 
manifest  only  by  great  diffuse  redness  and  some  swelling.  It 
shows  no  change  in  the  epithelium  and  no  macroscopic  vessels 
and  can  be  shrunk  aAvay  by  adrenalin,.  At  present  I  do  not  be- 
lieve this  to  be  a  lesion  to  be  classed  as  in  some  manner  hyper- 
plastic. I  know,  however,  that  it  may  make  the  entire  clinical 
picture  as  portrayed  in  this  chapter  and  that  it  may  endure 
any  length  of  time. 

There  remains  one  more  item  Avhich  I  feel  should  be  em- 
phasized. In  the  examination  of  a  case  it  is  of  course  the  rhi- 
nologist's  concern  to  determine  not  only  the  presence  of  secre- 
tion but  also  the  character  of  it.  Great  emphasis  is  always 
laid  on  the  presence  of  pus.  The  point  I  wish  to  make  in  this 
connection  is  the  appearances  of  the  epithelium  under  different 
conditions.  The  epithelium  on  a  normal  membrane  is  transpar- 
ent whether  viewed  in  the  perpendicular  to  the  surface  or  ob- 
liquely. When,  however,  the  thickened  epithelium  is  viewed 
obliquely  it  is  nearly  if  not  quite  opaque  and  on  the  sharp  con- 
vexities and  concavities  presented  in  the  olfactory  fissure  and 


HYPERPLASTIC    SPHENOIDITIS  139 

spheno-ethmoidal  recess  gives  the  impression  of  a  layer  of  pus 
or  seropiirulent  secretion.  This  is  emphasized  in  the  depths  of 
the  sphenoethmoidal  recess  around  the  sphenoidal  opening 
which  is  often  visible  in  good  light,  and  in  the  upper  meatus 
-around  the  post-ethmoidal  outlet.  Their  edges  appear  opaque 
and  the  depths  indistinctly  visible  so  that  the  appearance  of 
a  spot  more  or  less  like  pus  results.  The  differential  diagnosis 
may  be  made  usually  (and  without  great  difficulty)  in  a  light 
of  increased  brightness,  for  example  if  the  electric  arc  is  in- 
sufficient the  direct  sun  from  a  10  cm.  concave  glass  is  ample  to 
settle  all  question  as  to  what  the  spot  is.  Moreover,  should  it 
be  pus,  it  is  almost  invariably  greenish  yellow  or  yellomsh 
green  whereas  the  opaque  epithelium  is  wliite  or  very  slightly 
bluish  white.  The  spot  made  by  scant  pus  at  the  site  of  the 
sphenoidal  or  post-ethmoidal  outlet  is  readily  reproduced  in  the 
cadaver*^  by  the  instillation  into  the  cell  of  a  very  small  amount 
of  bismuth  hydroxide  in  suspension  to  flow  through  the  outlet 
into  the  nasal  fossa.  The  head  is  then  examined  by  reflected 
light  as  in  life.  Another  place  Avhere  the  obliquely  iUuminated 
epithelium  may  give  the  impression  of  pus  is  the  upper  choanal 
arc.  It  is  usually  marked  by  a  ridge  which  is  the  demarcation 
between  the  upper  limit  of  the  pharynx  and  the  back  part  of 
the  nose.  Here  it  may  appear  opaque  and  give  the  impression 
of  pus.  Just  anterior  to  the  ridge  is  often  a  sulcus  or  an  ex- 
panse that  reaches  as  high  or  higher  than  the  sphenoidal  out- 
let which  is  then  out  of  the  line  of  vision.  Secretion  on  this 
surface  therefore  cannot  be  seen.  Sometimes  it  may  be  seen 
with  Holmes'  pharyngoscope.  As  it  descends  it  would  of  course 
be  recognizable  Avhen  it  reached  the  ridge  and  began  to  descend 
into  the  pharynx,  if  it  remained  in  i^osition.  This  is  the  fact 
in  pharynges  of  considerable  size ;  i.  e.,  so  large  that  the  soft 
palate  is  not  long  enough  to  rise  to  that  height  and  so  cannot 
wipe  it  away.  But  in  smaller  phar^Tiges  the  palate  in  the  act 
of  SAvallowing  wipes  it  away  and  particularh'  is  this  true  in 
gagging  wliicli  frequently  hapj^ens  in  the  exainination.®^  Se- 
cretion on  or  over  the  ridge  therefore  is  very  often  not  allovred 
to  accumulate  but  is  constantly  mped  away.  The  rhinologist's 
judgment  here  may  he  furthermore  confounded,  not  only  by 
the  obliquely  illuminated  epithelium  Avhicli  as  stated  above  may 


140 


HEADACHES    AT^D    EYE    DISORDERS    OF    XASAL    ORIGIX 


give  the  impression  of  pus,  but  by  the  fact  that  pus  from  else- 
where within  the  reach  of  the  paLnte  may,  by  the  trowel-like 
action  of  its  upper  surface  during  the  act  of  swallowing  or  gag- 
ging, be  transferred  from  its  point  of  origin ;  e.  g.,  the  lower 
meatus  of  the  same  or  the  opposite  side  to  the  upper  choanal 


Fig.   75. — Showing   a    cell    1-2-3   which    appeared    to    be    the    sphenoidal    cell.      The    probe   5    shows 
that   the  veritable  sphenoidal  cell   6  is   behind  and   below   this.      4.  The  sella   turcica. 

arc  and  if  it  be  in  sufficient  amount  will  be  pushed  forward 
beyond  the  choanal  plane.  This  will  then  be  not  only  a  decep- 
tion but  one  produced  by  pus  really. 

Hyperplastic  post-ethmoidal  sphenoiditis  is  rarely  unilat- 
eral.   It  may  be  more  marked  on  one  side  than  the  other  and 


HYPERPLASTIC    SPHEXOIDITIS 


141 


the  configuration  of  tlie  district  may  interfere  with  its  recogni- 
tion, more  on  one  side  tlian  the  other.  These  facts  should  be 
borne  in  mind  i)articnlarly  where  the  diagnosis  is  a  matter  of 
serious  import ;  e.  g.,  where  a  serious  eye  lesion  exists,  and  the 
appearances  permit  of  the  diagnosis  only  on  the  opposite  side. 
Under  these  circumstances  I  have  operated  the  side  having  the 
eye  lesion,  despite  the  fact  that  the  appearances  did  not  per- 
mit of  the  diagnosis  on  that  side,  and  found  the  lesion  under 
the  microscope  and  have  been  rewarded  l)y  the  recovery  of  the 


Fig.   76. — Same  as  Fig.   75  showing  probe  .;  in  lower  cell.     1-2-3.  Upper  cell.     >   Sella  turcica. 

eye  lesion.  The  recognition  of  the  hyperplastic  process  on  the 
opposite  side  served  as  a  trustworthy  guide.  lTffenorde°"  ob- 
served that  hyperplastic  ethmoiditis  (anterior)  is  rarely  uni- 
lateral. He  states  that  it  may  develop  more  on  one  side  because 
of  "unfavorable  circumstances,"  e.g.,  a  deflected  septum.  But 
in  a  post-ethmoidal-spliciioidal  picture  such  an  etiological  fac- 


142 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


tor  does  not  exist.  Moreover,  I  doubt  if  that  he  the  correct 
interpretation  of  the  anterior  picture. 

A  feature  in  tlie  diagnosis  quite  aside  from  the  patholog- 
ical lesions  described,  exists  in  anomalous  anatomical  arrange- 
ments of  these  parts.  Failure  to  bear  these  possibilities  in 
mind  may  defeat  utterly  the  best  technical  efforts  of  rhinol- 
ogists. 

It  not  at  all  infrequently  happens  that  the  body  of  the 


Fig.  77. — Showing  an  upper  and  lower  subdivision  of  the  sphenoid  body.  /.  A  probe 
in  what  was  the  upper  cell.  =>.  The  remains  of  the  separating  shelf.  5.  The  lower  cell  opened 
down  in  the  pterygoid  process  as  far  as  the  bifurcation  of  the  plates.     4.  The  sella  turcica. 

sphenoid  is  shared  by  a  j^ost-ethmoidal  cell  as  well  as  the  sphe- 
noidal cell.  The  extent  of  this  may  vary  in  wide  limits.  A  cell 
which  seems  the  size  of  the  usual  sphenoidal  cell  may  occupy 
the  upper  part,  and  below  it  the  real  sphenoidal  cell  is  found. 
(Figs.  75,  76,  and  77.)     It  is  most  important  that  the  upper  cell 


HYPERPLASTIC    SPHENOIDITIS 


143 


be  opened  for  ocular  lesions  and  that  the  lower  cell  be  opened  for 
for  the  painful  lesions.  It  may  be  thought  that  confusion  here 
could  be  avoided  by  attention  to  their  outlets  and  utilizing  them 
in  the  operation,  I  do  not  believe  this  to  be  the  case.  There 
may  also  be  another  type  of  subdivision;  namely,  antero-pos- 


Fig.  78. — Showing  an  anterior  and  posterior  subdivision  of  the  sphenoid  body.  /.  The 
probe.  2-4.  Anterior  face  (this  line  has  been  retouched  to  show  better  in  the  reproduction). 
S.  Anterior  face   of  posterior  cell.     5.   Sella   turcica. 

terior.  (Compare  Fig.  78,  79,  and  80.)  A  cell  of  the  full  height 
of  the  body  may  not  infrequently  be  found  which  at  the  time 
of  operation  appears  to  be  the  veritable  sphenoidal  cell.  Later 
it  may  be  found  by  the  picture  of  the  probe  in  situ  that  the  real 
sphenoidal  cell  is  back  of  this.    Once  I  opened  three  cells  in  the 


144 


HEADACHES    AlsTD    EYE    DISORDERS    OF    NASAL    ORIGIN" 


body  of  the  splienoid,  each  in  the  antero-ijosterior  arrangement 
and  apparently  occupying  the  full  height  of  the  body.  Figs. 
81  and  82  show  a  large  splionoidal  sinus  hollowed  out  Avith  the 
pterygoid  process  to  the  bifurcation  of  the  plates. 

The  diagnosis  of  these  anomalies  is  made  by  taking  x-ray 
pictures  of  a  probe  placed  in  the  cell  whose  identity  is  in  ques- 
tion. Fig.  78  shows  a  probe  in  a  cell  which  I  believe  every  rlii- 
nologist  would  have  asserted  to  be  the  sphenoidal  cell.     The 


Fig.   79. — Showing    subdivided    sphenoid   body.      /.   Probe.      .'.   Anterior   face    of    anterior    cell.      j. 
Anterior  face  of  posterior  cell. 


70 


picture,  however,  shoAvs  the  sphenoidal  cell  below  it.  Fig.  VU 
shows  a  probe  in  Avhat  I  ])elieve  to  have  been  an  equally  decep- 
tive cell.  It  also  shows  another  cell  behind  it.  I  always  take 
these  pictures  in  cases  Avhich  have  not  been  benefited  by  opera- 
tion. The  other  cells  are  of  course  opened  as  soon  as  identified. 
In  this  way  I  have  relieved  some  ocular  and  painful  lesions 
where  previous  efforts  had  failed. 


HYPERPLASTIC    SPHEXOIDITIS 


145 


Another  aiiomah^  to  be  borne  in  mind  is  the  fact  that  the 
sphenoidal  cell  of  one  side  inay  exteiid  into  the  other  side  and 
occupy  it  ahnost  completely.  Such  a  cell  will  then  border  the 
optic  canal  of  both  sides.  (Fig.  83.)  A.  ()nodi^°  pointed  out 
this  fact.  But  it  also  borders  the  maxillary  and  Vidian  of  the 
opposite  side.  I  do  not  at  present  know  how  this  anomaly  may 
be  identified.  But  l^earing'  it  in  mind  I  have  operated  both  sides 
in  some  desperate  cases  where  the  resnlt  on  the  indicated  side 


Fig.   80. — Showing  probe    in   large   undivided   sphenoid   body. 


was  a  failure.     In  this  way  I  have  relieved  some  ocular  and 
painful  lesions  Avhich  were  apparently  hopeless. 

The  diagnosis  of  hyperplastic  or  suppurative  post-eth- 
moidal  sphenoiditis  in  children  is  difficult,  because  it  is  only 
seldom  that  the  child  may  l)e  controlled  for  a  satisfactory  post- 
nasal view.  Should  this  be  possible,  it  presents  no  other  diffi- 
culties.    A  palate  hook  sometimes  Init  not  ahvays  facilitates 


146 


HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


the  examination  in  children.  It  does  not  always  help  because  in 
the  small  nasopharynx  of  children,  it  is  possible  for  the  con- 
strictors to  contract  and  ol)literate  the  cavity  regardless  of  the 
position  of  the  soft  palate  which  of  course  may  be  held  forcibly 


Fig.   81. — Shows  probe  introduced  into  a  very   large  sphenoidal   cell   downward  to   the  bifurcation 

of  the   plates. 

forward.  If  the  child  cannot  be  controlled  for  a  postnasal  ex- 
amination, the  diagnosis  is  usually  still  possible  from  the  ante- 
rior nares  but  is  much  more  difficult.  I  have  found  hyperplas- 
tic postethmoidal  sphenoiditis  to  be  a  very  frequent  lesion  in 


HYPERPLASTIC    SPHENOIDITIS 


147 


childhood  from  as  early  as  the  fourth  year,  producing  headache 
and  eye  lesions. 

A  palate  hook  in  the  adult  makes  practically  every  naso- 
pharynx possible  of  a  satisfactory  examination.  Fig.  84  shows 
a  palate  hook*  that  locks  in  position  automatically  and  releases 
instantly  when  necessary  because  of  cough  or  vomiting. 


Fig.  8^. — Same  as  Fig.   cSl   taken  from  in  front. 


It  is  interesting  to  observe  the  behavior  of  a  coryza  that 
affects  one  part  of  the  nose  in  full  violence  and  leaves  the 
other  undisturbed  liy  anything  more  than  a  slight  congestion 
or  not  even  that.     The  explanation  for  this  cannot  at  present 


*To   be    purchased   from   \'.    Mueller   &   Co.,    Chicago,    111. 


148 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


Fig.  83. — Shows  the  left  half  of  specimen.  i.  Right  sphenoidal  sinus  extending  into 
left  side  to  border  left  optic  canal  ,.?.  Left  sphenoidal  sinus  5  also  borders  left  optic  canal.  A 
post-ethmoidal  cell  4  also  borders  left  optic  canal. 


Fig.  84. — Two  views  of  palate/  hook.  The  upper  surface  of  the  shaft  is  milled  which 
provides  infallible,  instantaneous  and  secure  locking  when  the  prongs  press  the  upper  lip.  The 
short  sleeve  B  is  thereby  rotated  upon  its  transverse  axis  locking  it  into,  the  milled  surface 
of  the  shaft.  It  is  instantly  released  by  pulling  forward  the  tip  A.  To  be  had  of  \'.  Mueller 
&  Co.,   Chicago,  III. 


HYPERPLASTIC    SPHENOIDITLS  149 

he  given.  It  may  be  in  some  way  a  l)aeteriologieal  phenomenon. 
It  is  prohahly  a  homologue  of  phenomena  elsewhere ;  e.  g.,  in 
the  skin.  No  explanation  can  be  given  for  why  measles  make 
one  pictnre  on  the  skin  and  secondary  syphilis  another.  I 
have  twice  seen  the  prevailing  localizing  to  he  post-eth- 
moidal-sphenoidal  in  fnll  virulence  and  at  the  same  time  al- 
most nniformly  leaving  the  anterior  sinuses  undisturbed.  The 
first  occasion  was  in  St.  Louis,  1905-1908.  The  second  1912- 
1916.  In  these  years  anterior  sinus  infections  were  quite  rare, 
not  onh'  in  my  o'wii  experience,  but  in  tiiat  of  my  colleagues  who 
also  commented  on  the  fact.  It  vras  also  true  in  the  clinic.  The 
ordinary  coryza  wliich  affected  netirh'  everyone^  young  or  old, 
was  a  post-ethmoidal-sphenoidal  inflannnation  with  or  without 
pus.  In  other  years  anterior  sinus  infections  have  been  quite 
commonplace.  Bacteriological  investigation  of  these  problems 
has  failed  to  give  any  information. 

The  question  of  the  association  of  ocular  tuberculosis  with 
the  nose  was  raised  by  Dr.  AV.  II.  Luedde,^'"''  1901.  He  injected 
tuberculin  into  some  of  his  cases  of  ocular  tuberculosis  and 
found  the  reaction  in  the  eye.  At  the  same  time  I  found  a 
slight  reaction  in  what  appeared  a  typical  hyperplastic  post- 
ethmoidal  sphenoiditis.  Dr.  W.  M.  C.  Bryan  and  I  liave  tried 
to  get  a  tuberculin  reaction  in  other  typical  cases  without  oc- 
ular lesions,  but  so  far  have  failed. 

Bacteriological  investigation  of  hyperplastic  post-eth- 
nioidal  sphenoiditis  has  so  far  been  negative.  The  x-ray  in 
my  experience  has  failed  to  help  in  the  diagnosis  of  hyper- 
plastic post-ethmoidal-sphenoidal  diagnosis.  It  is  of  jDara- 
mount  value  in  determining  cell  anomalies,  showing  probes  in 
positions  which  determine  tliese. 

PROGNOSIS 

Prognosis  in  the  sphenoidal  region  seems  to  me  to  present 
features  for  consideration  not  found  elsewhere.  The  matter  of 
drainage  here  is  often  impossible  because  of  an  irregularly 
shaped  (large)  cavity  which  cannot  be  drained  from  any  place 
in  the  nose  or  from  any  one  place,  wherever  situated.  Such  a 
cavity  may  extend  into  the  great  and  small  wings,  into  the 
pterygoid   process   and   down  the   clivus   of   Blumenbach,   and 


150  HEADACHES    AND    EYE    DISOEDERS    OF    NASAL    ORIGIN 

liave  obstructing  partitions  in  it.  In  contrast  to  sncli  possibil- 
ities it  is  very  rare  indeed  tliat  a  frontal  simis  is  not  drained 
by  a  satisfactory  inlet  to  it.  This  is  true  for  the  maxillary 
antrum  and  usually  for  the  ethmoidal  cells  also.  The  excep- 
tion in  the  ethmoid  is  so  rare  as  to  l)e  practically  negligible, 
although  it  does  exist.  But  Avere  the  difficulties  in  the  prognosis 
here  a  question  of  drainage  only  they  would  be  comparatively 
simple.  Drainage  or  ventilation  of  the  frontal,  ethmoid,  and 
antrum  is  sufficient  to  stop  pain  and  to  effect  the  cure  in  all  but 
very  rare  exceptions — these  l^eing  cases  of  very  long  stand- 
ing. For  the  hyperplastic  sphenoid  the  best  drainage  does  not 
stop  the  pain  except  very  rarely.  Part  of  the  sphenoidal  floor 
may  be  removed,  Avliich  in  a  cell  of  simple  arrangement  gives 
perfect  drainage.  But  it  does  not  solve  the  problem.  Some  of 
the  hyperplastic  sphenoids  (some  of  the  Avorst)  are  dry.  The 
pain  in  these  cases  is  not  made  by  pressure  of  confined  secre- 
tion as  in  an  obstructed  frontal  empyema.  It  may  be  made  in 
great  seA^erity  by  a  small  area  of  moderate  grade  inflammation 
if  situated  at  the  proper  place;  e.g.,  at  the  point  Avhere  the 
maxillary  nerve  passes,  particularly  through  the  foramen 
rotundum;  namely,  the  loAver  lateral  antei'ior  part  of  cell,  or, 
on  the  floor  Avhere  the  Vidian  passes.  I  haA^e  seen  this  fre- 
quently by  the  nasopharyngoscope  and  I  haA^e  seen  such  a  lesion 
diminish  the  Adsion  greatly  Aviien  situated  on  the  site  of  the 
optic  canal,  to  Avit  the  upj^er  ont(M'  anterior  aspect  of  the  usual 
sinus.  I  have  seen  these  as  the  primary  pictures ;  that  is,  at 
the  time  the  sphenoid  Avas  opened,  to  disappear  by  treatment 
Avith  recoA^ery  from  the  symptoms  and  reappear  later  as  a  local- 
ized coryza  (seA^eral  times  in  the  same  patient)  Avith  reestab- 
lishment  of  the  original  symptoms;  namely,  pain  and  blindness. 
The  degree  of  hyperplasia  in  these  cases  is  often  slight  or  even 
nil.  I  haA^e  construed  them  as  having  very  thin  avails  separat- 
ing the  maxillary ,  Vidian  and  optic  nerves.  Any  disturhance 
in  the  cell  quickly  affects  these  neighboring  nerves  by  the  in- 
flammation or  its  toxin  passing  tJi rough  the  bone  and  membrane 
to  the  nerves.  This  argument  is  also  borne  out  by  therapy. 
These  are  the  cases  most  quickly  and  satisfactorily  helped  by 
antiphlogistic  and  analgesic  applications  ivithin  the  cell. 

In  sharp  contrast  to  these  cases  are  others  tvhere  upon 


HYPERPLASTIC    SPHENOIDITIS  151 

Opening  the  cell  the  membrane  is  thick,  rough  and  dry  with  no 
markings  at  the  sites  of  the  maxillary,  Vidian  or  optic.  The 
hyperplastic  hone  process  is  shown  hy  the  microscope  to  he 
well  mcirked.  Therapy  in  these  is  disappointing  or  at  least 
very  slowly  satisfactory.  Months  pass  with  the  ]}est  efforts  of 
the  rhinologist  ahiiost  in  vain.  Contiimed  effort  however  over 
a  period  of  several  years  will  usually  show  a  slow  improvement. 
At  the  end  of  a  year  and  a  half  to  three  years  the  case  shows 
definite  betterment.  Were  the  eye  disturliance  slight  it  may 
have  recovered.  Were  it  more  than  slight  it  will  be  consider- 
ably hetter.  AVere  it  headache  it  may  have  so  far  recovered 
that  the  patient  has  much  time  free  of  pain.  Coryzas  of  any 
grade  reestablish  the  headache  more  or  less.  I  have  construed 
these  not  as  simple  inflammation  or  toxin  transmission  lesions, 
hut  as  thickening  bone  lesions  tvith  consequent  narrowing  of 
the  cancds  through  which  the  nerves  pass.  Part  of  the  narrow- 
ing may  be  a  periostitis  in  the  canal.  But  with  or  without  peri- 
ostitis the  increase  of  the  hone  volume  7nust  encroach  on  the 
canals.  Such  a  narrowing  means  pressure  on  the  nerves  ivith 
pain.  Long  continued  therapeutic  effort  ivill  finally  reduce  the 
volume  to  some  extent.  And  furthermore  in  later  years  the 
rarefying  state  ensues  and  further  helps  the  case.  I  believe  this 
is  what  happens  when  the  case  begins  to  improve  spontaneously 
some  time  after  the  fiftieth  year  as  has  been  observed  by  neu- 
rologists in  cases  of  megrim.  The  megrim  gets  better  without 
operation. 

Secretion  and  gravity  apparently  play  a  definite  part  in  the 
first  class  of  cases.  The  watery  secretion  gravitates  to  the 
lower  part  of  the  cell  away  from  the  optic  canal.  This  seem 
to  me  to  explain  the  greater  numl)er  of  headaclies  and  the 
smaller  number  of  ocular  lesions  (as  previously  stated).  The 
optic  canal  is  almost  never  separated  from  the  post-ethmoid 
or  sphenoid  cells  by  any  considerable  thickness  of  bone,  whereas 
the  maxillary  and  Vidian  are,  in  a  percentage  of  cases.  The 
percentage  is  not  large  according  to  my  observation  but  I  can- 
not now  put  it  in  figures. 

It  appears  to  me  to  follow  in  logical  sequence  that  in  the 
first  class  of  cases  the  prognosis  is  for  speedy  relief  from  the 
symptoms,  and  that  they  must  necessarily  be  reestablished  at 


152  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORlGIISr 

the  time  of  a  coryza.  The  infection  ''eoryza"  in  these  parts 
may  be  of  grades  so  sliglit  that  the  patient  is  not  cognizant  of 
it  and  still  make  the  ocnlar  or  the  painfnl  lesions.  The  acutely 
inflamed  area  ma}^  however  be  seen  Avith  the  pharyngoscope 
after  the  cells  are  opened.  And  for  the  second  class  of  cases 
the  prognosis  is  also  for  relief  but  it  nmst  needs  be  slower 
and  less  complete,  althongh  in  the  long  run  the  result  is  pre- 
emlneutly  worth  the  effort  it  took  to  get  it.  These  cases  have 
seemed  to  me  to  be  less  disturbed  by  corj^zas. 

The  post-ethmoidal-sphenoidal  radical  operation  properly 
performed  in  the  first  class  of  cases  almost  always  gives  a  tech- 
nical result  that  remains  satisfactory;  that  is,  the  openings  of 
the  cells  remain  as  the  operator  makes  them.  In  the  second 
class  they  almost  always  get  smaller  and  very  frequently  close 
up  completely  and  so  nmst  be  made  gain,  often  several  times. 

In  later  life  an  involution  of  the  hyperplastic  changes — 
rarefying  osteitis — takes  place,  sometimes  beginning  about  the 
fiftieth  year  and  sometimes  latci-.  I  have  seen  this  in  nnoperated 
cases  accompanied  by  corresponding  cessation  of  symptoms,  (in 
one  case  an  ophthalmic  migraine). 

TREATMENT 

Tlie  relief  of  low  grade  hyperplastic  post-ethmoidal  sphe- 
noiditis  wliether  for  headache  or  eye  lesions,  in  my  experience, 
has  often  been  accomplished  b)'  the  sedulous  use  of  a  one  and 
one-half  or  two  per  cent  alkaline  saline  solution  twice  or  thrice 
daily  snutfed  from  the  palm  of  the  hand,  and  the  face  then 
quickly  turned  up  so  as  to  make  that  region  the  lowest  part 
of  the  nose,  to  be  flooded  by  gravity.  The  same  result  is  se- 
cured l)y  the  use  of  a  douche  which  pours  into  the  nose.  That 
necessitates  the  face  being  turned  up  to  l)egin  Avith.  I  use  an 
ancient  English  mixture,  sodium  chloride,  sodium  bicarbonate 
and  sugar  of  milk*  equal  parts.  I  prefer  to  have  this  made 
into  tablets  of  known  weight,  for  the  convenience  of  the  pa- 
tient. They  are  added  to  water  to  make  the  solution  one  and 
one-half  to  two  per  cent.  That  solution  is  definitely  heavier 
than  the  blood  serum  and  nmst  set  up  an  osmotic  current  away 
from  the  tissues.    That  strength  is  at  the  same  time  non-irritant. 

*Sugar   of   milk   seems    to    make   the   solution   pleasanter   in   the    nose.      It   is    not    necessary. 


HYPERPLASTIC    SPHENOIDITIS  153 

It  dirniiiislu'S  the  volume  of  the  tissues  without  irritation  or  re- 
action sueii  as  follows  stronger  astringents  or  adrenaline  solu- 
tions. It  is  of  course  cleansing  also,  bnt  other  solutions  may 
be  so  too,  and  not  accomplisli  the  end  if  they  irritate.  This 
is  moreover  exemplitied  by  the  same  solution  if  it  is  too  weak 
or  too  strong,  either  of  Avhich  irritates. 

The  occasional  ajoplication  of  a  two  per  cent  silver  nitrate 
solution  in  small  amount  is  also  helpful.  A  solution  of  phenol 
1.  c.c,  liq.  iodi  comp.  4.,  c.c.  water  200  c.c,  is  also  helpful  occa- 
sionally applied  in  5  c.c.  amounts  with  a  syringe  the  point  of 
which  is  placed  in  the  olfactory  fissure  at  al)out  its  middle. 
It  is  injected  with  some  force.  But  more  satisfactory  in  my 
experience,  is  the  dail>'  use  of  one-half  or  one-third  per  cent 
solution  of  phenol  in  oleum  petrolatum  in  5  c.c.  amounts  injected 
forcil)ly  into  the  olfactory  fissure  l)y  a  syringe  (fine  point) 
placed  in  the  fissure  at  al)out  its  middle.  This  is  painless  and 
provokes  no  reaction.  I  have  proved  on  the  cadaver  that  some 
of  the  solution  thus  instilled  enters  the  post-ethmoidal  and  sphe- 
noidal cells  in  skulls  where  the  openings  are  of  the  usual  size. 
This  oil  is  furthermore  thick  enough  to  remain  in  its  place 
for  some  time  (one-half  to  two  hours),  which  helps  its  effect. 
When  the  pain  is  severe  a  solution  of  one-half  per  cent  cocaine 
alkaloid  in  oleum  petrolatum  may  be  thus  instilled.  Both  the 
phenol  and  cocaine  are  analgesic.  Many  low  grade  recent  cases 
(with  headache  or  eye  lesions)  are  satisfactorily  treated  by 
these  means.  The  question  arises  here,  naturally,  "Why  not 
instill  the  solution  into  the  sphenoid  by  cannula?"  One  reason 
for  not  adopting  this  as  a  routine  i^lan  is  that  the  daily  effort 
for  this  purpose  in  the  average  nose,  inflicts  a  degree  of  trauma 
that  is  followed  by  loo  much  reaction  to  secure  the  desired 
effect.  Another  reason  is  that  the  opening  of  the  sphenoid  is 
often  so  placed  that  it  cannot  he  catheterized  while  tlie  middle 
turbinate  is  in  place.  When  the  patient  cannot  be  treated  l)y 
the  rhinologist,  I  give  him  tlu-  phenol  oil  mixture  to  pour  into 
his  nose  as  he  does  the  alkaline  saline  solution,  not  believing 
hoM^ever  that  it  in  this  way,  enters  the  sphenoid. 

The  suction  treatment  recently  advocated  by  Coffin  aaid 
Harmon  Smith  for  the  suppurating  sinuses  cannot  be  of  help 
for  these  cases  because  they  are  not  suppurating  cases.     Some 


154  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIlSr 

have  a  scant  tliiii  secretion  tliat  could  not  be  sncked  out  of  the 
lower  part  of  the  sphenoid  and  many  are  without  any  secretion. 

Mention  should  be  made  of  change  of  climate  or  atmos- 
pheric or  hygienic  conditions  as  a  possible  therapeutic  influence. 
I  have  so  far  failed  to  recognize  these  as  in  any  way  potent 
factors  for  or  against  the  development  of  hyperplastic  post- 
ethmoida]  sphcnoiditis.  Occasionally  a  patient  thinks  he  is 
benefited  by  a  ''change  of  some  sort." 

Should  these  means  fail  the  sinuses  should  be  opened.  For 
this  purpose  intranasal  surgery  if  properly  done  seems  to  me 
to  offer  all  that  is  possible.  Extra  nasal  surgery  in  some  old 
and  far  advanced  degrees  of  ])ath()logical  alterations,  (sup- 
puration, granulation  and  necrosis)  of  the  cavities,  may  offer 
possibilities  beyond  those  of  intranasal  surgery.  But  in  these 
cases  of  hyperplastic  post-ethmoidal  sphenoiditis,  such  condi- 
tions, so  far  as  I  know,  are  never  found.  The  most  advanced 
change  I  have  so  far  found  has  been  broad  based  edematous, 
polypoid  swelling  witliout  pus  or  recognizable  secretion.  This 
has  usually  subsided  after  opening  the  cells. 

Surgery  of  the  Paranasal  Cells 

The  upper  paranasal  cells  may  ])e  approached  by  two  in- 
tranasal routes — an  anterior  and  an  internal.  The  anterior 
was  probably  sought  in  an  eifort  to  save  the  middle  turbinate. 
It  was  first  utilized  liy  Schaeffer''^  who  punctured  the  wall  of 
the  nose  anterior  to  the  middle  turbinate  with  a  small  curette. 
This  usually  enters  a  prefrontal  cell  of  the  ethmoid.  Through 
this  he  reached  the  uncinate  process  and  removed  it  to  gain 
entrance  to  the  frontal  sinus.  He  then  proceeded  backAvard 
to  open  thp  ethmoid  cells  and  fui'ther  backward  to  open  the 
sphenoid,  operating  in  a  direction  from  in  front  upward  and 
backward,  in  a  plane  lateral  to  the  middle  turbinate  which  was 
left  in  situ.  This  Avas  done  with  the  desire  to  save  the  turbinate 
for  its  function.  If  this  were  not  the  idea  of  Schaeffer  it  has 
been  that  of  its  subsequent  advocates  (Uffenorde^^).  Schaef- 
fer's  text  is  not  clear  as  to  whether  he  removed  the  imcinate 
process.  Uffenorde,  however,  is  very  clear.  The  only  condi- 
tion in  which  that  procedure  seems  to  me  advantageous  is 
where  there  is  an  unusually  wide  middle  meatus  Avith  a  cor- 


HYPERPLASTIC    SPHEXOIDITIS  155 

respondiiigly  wide  nasal  fossa.     Here  it  is   advantageous   to 
save  the  middle  turbinate  to  avoid  subsequent  drying. 

I  am  one  of  those  opposed  to  this  procedure  for  several 
reasons.  First,  it  is  by  no  means  the  rule  that  it  is  the  cells 
themselves  that  are  diseased;  e.  g.,  a  normal  turbinate  may  l^e 
crowded  to  the  lateral  Avail  b}^  a  septum  tubercle  combined 
Avith  a  slight  deflection  or  sAvelling;  or  hypertrophy  of  the  tur- 
binate may  exist  l)locking  some  secretion  Avliicli  stops  as  soon 
as  drainage  is  given.  Second,  in  an  active  hyperplastic  process 
that  has  included  the  bone  in  its  activities,  tlie  curette  is  fol- 
loAved  by  great  bone  reproduction  which  defeats  the  object. 
Under  these  conditions  it  has  been  nmch  more  satisfactory  to 
remove  by  a  clean  cut  the  diseased  tissue  Avhich  can  be  done  by 
the  internal  approach.  Third,  the  anterior  approach  must  be 
more  dangerous  than  the  internal  approach.  The  latter  re- 
moves the  middh'  tui-l)inate  then  permitting  a  cut  of  the  tis- 
sues instead  of  from  below  and  in  front  upAvard  and  back- 
Avard — from  aboA^e  and  behind  doAvuAvard  and  forAvard.  Fourth, 
the  internal  approach  may  be  most  conserA^atiA^e.  Tlie  remoA^al 
of  the  middle  turbinate  takes  as  it  Avere,  the  flap  A^alve  otf  the 
normal  outlets  of  the  frontal,  maxillary  antrum  and  anterior 
ethmoid.  The  more  these  outlets  are  left  midisturbed,  that  is, 
the  less  their  epithelial  coA^ering  is  injured,  the  more  satisfac- 
tory. In  cases  of  adA^anced  disease — suppuration  A\'ith  gran- 
ulation and  necrosis — of  course  all  the  tissues  must  be  removed. 
But  in  simple  suppuration  simple  drainage  suffices.  For  these 
reasons  my  choice  is  the  internal  approach.  Tliis  consists  pri- 
marily in  the  remoA^al  of  the  middle  turJiinate  Avliich  lies  OA^er 
(internal  to)  the  openings  of  the  frontal,  anterior  ethmoid  and 
maxillary  cells.  The  simple  remoA^al  of  the  pendulous  tur- 
binate must  be  considered  the  simplest  and  most  conservative 
procedure.  The  argument  is  made  that  it  is  desirable  to  con- 
serA^e  the  turbinate.  Experience  here,  hoAvever,  proA^es  that  the 
remoA^al  of  the  turbinate  is  not  folloAved  by  drying  or  the  sen- 
sation of  cold  from  the  inspired  air,  as  might  he  argued  on 
theoretical  ground ;  nor  by  any  otlier  disturliance  Avithin  the 
nose.  The  next  step  in  the  direction  of  radical  procedure  is 
the  high  (cribriform)  cut  on  the  lateral  Avail  Avhicli  remoA^es 
the  innermost  part  of  the  ethmoid  capsule  as  Avell  as  the  mid- 


156  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

die  turbinate.  Tjiis  opens  the  prefrontal  cells,  tlie  complete 
infmidibulnni  and  tlie  nasal  wall  of  the  remaining  ethmoid  cells. 
The  complete  radical  procedure  removes  the  remaining  part  of 
the  floor  of  the  frontal  sinus  with  the  remaining  part  of  the 
ethmoid  capsule  leaving  the  paper  plate.  Mosher's'®  operation 
takes  the  anterior  route  but  utilizes  the  middle  turbinate  as 
landmark  or  guide,  and  then  removes  it.  As  a  finished  pro- 
cedure it  is  the  radical  intranasal  operation  for  the  upper 
paranasal  cells  rendered  safer  by  utilizing  the  turbinate  as  a 
guide. 

For  the  maxillary  antrum  the  effort  for  drainage  or  ven- 
tilation is  to  leave  an  opening  at  its  lowermost  part  into  the 
nose.  At  the  present  time  the  older  procedures  which  provided 
some  other  opening  to  permit  washing  seem  to  have  been  uni- 
versally abandoned  for  self-evident  reasons.  Technique  for 
the  relief  of  the  antrum  may  be  divided  into  that  which  saves 
the  lower  turl)inate  and  that  Avliich  removes  it  in  the  effort  to 
provide  drainage  or  ventilation.  The  conservation  of  the  tur- 
binate here,  is  far  more  important  than  tliat  of  the  middle  tur- 
binate for  the  upper  cells  and  presents  no  difficulties  or  ob- 
jections. In  most  noses  wdiere  the  middle  turbinate  has  been 
removed  for  the  relief  of  the  upper  cells  it  is  imperative  to 
save  the  lower  turbinate  if  the  nasal  functions  of  moistening, 
warming  and  filtering  the  inspired  air  are  to  be  preserved. 
Removal  of  it  leaves  a  too  wide  cliannel  permitting  a  direct 
blast  of  the  dry  cold  impure  air  into  the  pharynx.  The  patient 
then  suffers  from  a  dry,  more  or  less  crusted,  phfirynx  for  life. 

In  addition  to  the  above  descril)ed  procedure  is  to  be  recom- 
mended the  removal  of  the  floor  of  the  frontal  sinus  in  cases 
where  it  is  found  after  the  cril^riform  turbinectomy,  that  the 
inlet  to  the  frontal  sinus  has  been  ol)]  iterated.  This  was  first 
conceived  and  executed  by  E.  Fletcher  Ingals,'-  who  passed  a 
small  probe  into  the  sinus  to  be  used  as  a  guide  to  limit  the 
posterior  cranial  cut  of  a  drill  used  to  remove  the  anterior 
part  of  the  floor  of  the  sinus,  wliich  is  here  made  of  heav>^ 
bone.  After  the  opening  has  been  made  sufficiently  large,  a  gold 
tube  wliich  has  been  split  in  several  places  longitudinally  for  a 
distance  of  two-thirds  cm.  from  its  upper  end  and  spread  out 
to  resemble  a  funnel,  is  ijlaced  in  the  opening.     The  spreading 


HYPERPLASTIC    SPHEXO.DITIS  157 

of  the  upper  end  is  controlled  at  the  time  of  introduction  hy 
confining  the  split  parts  in  a  gelatine  cap.  This  facilitates  its 
introduction.  Later  the  cap  melts,  the  end  spreads  out  and  is 
in  tins  way  self-retainiiig.  To  prevent  the  tn])e  from  slipping 
up  into  the  sinus  it  carries  a  flange  on  its  lower  end. 

The  advantage  of  removing  the  floor  of  the  frontal  sinus 
has  ai^pealed  to  other  surgeons  who  have  modified  the  pro- 
cedure more  or  less;  e.g.,  Halle, -^  Watson-AVilliams ;°*  and  re- 
cently Lothrop"  has  proposed  to  convert  the  two  frontals  into 
one  by  the  removal  of  the  frontal  septum,  and  then  to  remove 
the  floor  of  the  combined  cells  with  that  part  of  the  nasal  sep- 
tum encountered  in  the  downward  progress  of  the  procedure. 
Lothrop's  operation  is  external.  Halle's  and  AVatson-Williams' 
are  intranasal.  The  difficulty  met  with  in  these  procedures  is 
to  maintain  an  opening  with  the  nose ;  i.  e.,  to  make  one  that  re- 
mains permanent.  Lothrop's  undoubtedly  makes  the  largest 
opening.  Ingals  avoids  closing  by  the  self-retaining  gold  tube. 
In  contradistinction  to  these  procedures  is  that  (the  author's) 
which  lays  open  tho  full  extent  of  the  infuii(li])nlum  l)ut  leaves 
its  epithelial  (permanent)  linings  undisturbed.  Such  an  outlet 
or  inlet  remains  permanent.  The  only  thing  Avhich  can  close  it  is 
the  advance  of  the  hyperplastic  osteitis  under  the  membrane. 
When  no  connnunication  lietween  the  nose  and  infundibulum 
exists  the  floor  must  ])e  removed.  My  experience  is  that  the 
patient  has  far  less  trouble  Avitli  Ingals'  tube  in  jDosition.  Kil- 
lian's"^  and  the  other  radical  external  frontal  operations  are 
uot  designed  for  this  class  of  cases. 

I  have  always  thought  that  the  surgery  of  the  paranasal, 
•especially  the  upper  cells  should  be  in  the  charge  of  the  sur- 
geon who  is  thoroughly  learned  in  the  anatomy  of  the  parts  and 
who  possesses  the  skill  to  execute  that  Avliich  he  should 
thoroughly  understand.  Shortcomings  in  either  of  these  qual- 
ifications is  most  unfortunate  for  the  patient  for  the  reasons 
(1)  that  surgery  imperfectly  performed  at  the  initial  operation 
is  difficult  or  often  impossible  of  satisfactory  later  correction 
because  of  the  loss  of  landmarks  and  the  reproduction  of  the 
bone  that  is  so  hard  that  it  is  at  times  almost  impossible  to  deal 
with  it  satisfactorily.  Of  course  a  drill  or  a  burr  can  cut  bone 
of  any  degree  of  hardness,  ])ut  wlien  these  instruments  must 


158  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

cut  upward  and  backward,  the  surgeon  becomes  timid  and  fails 
to  reach  the  furthermost  points  at  which  the  difficulties  lie.  (2) 
Surgery  improperly  performed  for  the  relief  of  eye  lesions, 
may  not  only  fail  to  relieve,  l)ut  may  make  them  rapidly  worse. 
I  have  seen  this  happen.  Personally  I  cannot  but  feel  that  post- 
ethmoidal-sphenoidal  surgery  for  the  relief  of  e^'e  lesion  is 
always  fraught  with  great  responsibility.  For  this  reason  I 
feel  that  it  should  be  executed  only  upon  the  basis  of  a  definite 
diagnosis.  To  be  satisfactory  it  must  always  be  complete  be- 
cause we  have  no  way  to  tell  which  of  the  post-nasal  cells  is 
doing  the  damage.  For  this  reason  the  simple  opening  of  the 
sphenoidal  sinus  from  its  natural  opening  cannot  be  recom- 
mended if  we  are  to  accomplish  the  greatest  good  for  the  great- 
est number.  At  the  present  time  this  procedure  is  recommended 
by  an  occasional  author,  because  it  is  so  easy  and  simple. 
I  believe  this  judgment  rests  on  an  insufficient  knowledge  of  the 
anatomy  of  this  district.  And  while  saying  this,  I  am,  more- 
over, fully  conscious  that  an  occasional  headache  or  eye  lesion 
may  be  and  is  relieved  liy  this  easy  and  simple  procedure.  But 
should  it,  as  it  often  does,  fail,  the  second  operation  which  must 
quickly  follow  must  l)e  performed  under  much  less  advanta- 
geous conditions;  to  wit,  reaction,  swelling,  l)leeding  and  in- 
creased difhculty  in  keeping  one's  bearings,  (For  the  anatomy 
bearing  upon  these  questions  see  page  57).  Furthermore,  the 
pathological  process  in  the  post-ethmoidal  and  sphenoidal  si- 
nuses so  constantly  involves  both  sinuses,  that  it  is  a  difficult 
question  to  decide  whether  they  are  ever  wholly  separately  in- 
volved. It  is  a  question  corresponding  to  whether  the  frontal 
sinus  is  ever  involved  without  that  of  the  anterior  ethmoid. 
For  these  reasons  T  feel  that  the  only  procedure  that  einl)odies 
good  judgment  and  security  for  all  cases  is  the  complete  post- 
ethmoidal-sphenoidal  operation,  as  described  in  the  succeeding 
pages.  I  furthermore  believe  that  the  best  judgment  calls  for 
a  complete  cribriform  cut  of  the  nasal  wall  of  the  anterior 
ethmoid  extended  to  the  complete  cribriform  cut  of  the  tur- 
binate, thereby  not  only  removing  the  entire  middle  turbinate 
but  opening  the  entire  ethmoidal  capsule  with  the  infundil)ulum 
to  its  full  extent,  whether  these  cells  be  involved  at  the  time 
or  not.    A  small  stump  (one-tliird  cm.)  of  the  posterior  tip  of 


HYPEEPLASTIC    SPHEXOIDITIS  159 

the  middle  turbinate  should  be  left.  It  is  clinically  negligible 
and  serves  as  a  landmark,  useful  should  any  subsequent  pro- 
cedure be  necessary.  I  believe  this  to  be  the  best  judgment 
because  when  the  anterior  half  of  the  turbinate  is  saved  it  later 
enlarges  so  as  to  necessitate  further  surgical  interference. 
Hajek-^macle  this  observation  on  the  lower  turbinate  where  the 
posterior  half  was  saved  in  intranasal  antrum  operations. 
When  the  complete  sphenoidal-ethmoidal-frontal  operation  is 
properly  i)erforraed  for  the  usual  case,  the  result  remains  per- 
fect for  many  years  if  not  forever.  This  may,  however,  oc- 
casionally be  not  true  when  the  h^^perplastic  process  in  the  bone 
is  of  very  high  grade  in  younger  patients.  The  bone  reproduc- 
tion then  may  be  so  great  and  rapid  as  to  require  secondary 
operation  at  a  future  time. 

I  have  never  seen  any  functional  disturbances  as  the  result 
of  the  complete  operation. 

In  the  procediire  for  the  relief  of  the  frontal  sinus,  I  re- 
move the  middle  turl)inate  tliree-fourths  back  in  order  to  also 
free  the  outlets  of  the  anterior  ethmoidal  cells  completely.  This 
leaves  a  small  stump  posteriorly  which  is  helpful  as  a  landmark 
should  a  subsquent  operation  be  needed.  It  becomes  hyper- 
plastic or  hypertrophic  later  but  remains  clinically  negligible, 
because  its  position  does  not  obstruct  any  of  the  outlets.  This 
is  not  true  for  the  anterior  half  of  the  turbinate  wliich  obstructs 
the  frontal  and  ethmoidal  outlets  when  it  enlarges. 

The  Author's  Technique 

The  author's  technique^'  for  the  upper  cells  may  be  com- 
bined for  all  or  separated  into  that  for  the  single  cells.  Its 
advantage  (and  original  feature)  is  that  it  cuts  alivays  doivn- 
ward  and  fortvard,  that  is  aliroifs  in  the  direction  of  safety. 

Anaesthesia. — It  may  be  executed  under  local  or  general 
anaesthesia.  It  has  always  seemed  to  me  that  there  is  more 
bleeding,  under  ether  anaesthesia  which  adds  much  to  the  in- 
convenience and  confusion  of  the  surgeon.  Under  these  condi- 
tions, it  is  easier  for  him  to  lose  his  beai-ings  which  may  pre- 
vent its  perfect  performance  or  be  disastrous.  On  the  other 
hand  the  consciousness  of  the  patient  sometimes  makes  the  sat- 
isfactory control   of  him   difficult   or  impossible,   especially  in 


160  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

hysterical  patients.  This  difticulty,  however,  is  usually  con- 
trolled by  the  administration  of  a  small  dose  of  morphine  one- 
half  hour  before.  Its  effect  is  .greatly  intensified  by  the  addi- 
tion of  a  small  dose  of  hyoscine  (moi-})hine  Yq  gr.  (0.01  gm.) 
hyoscine  ^200  g"i".  (0.0003  gm.)  In  this  way  I  have  seen  the 
greatest  anxiety  and  apprehension  allayed.  Cocaine  has  often 
been  impotent  at  the  time  of  great  fear  (in  my  experience),  and 
perfectly  potent  and  satisfactory  in  the  same  patient  who  had 
previously  had  a  quieting  dose  of  morphine — hyoscine.  For 
these  reasons  the  psychical  state  of  the  patient  should  be  care- 
fully estimated.  Much  post-operative  nerv^ous  depression — 
^'neurasthenia"  may  be  avoided  if  aiixiety,  apprehension  and 
fear  can  he  eliminated  at  the  time  of  ox)erating.  These  facts 
are  well  known  to  experienced  rhinologists.  I  1)elieve  them, 
however,  to  always  merit  emphasis,  and  especially  so,  when  the 
patient  to  be  considered  is  one  wlio  lias  suffered  the  harassing 
headaches  of  these  lesions  for  months  and  years.  Most  of 
these  patients  were  long  ago  adjudged  "neurotic"  and  well 
they  might  be.  I  know  of  few  Ijodily  states  1)etter  calculated 
to  make  the  ablest  bodied  "neurotic"  than  the  endless  severe 
suffering  that  many  of  these  patients  have  endured,  some- 
times from  childliood.  The  neurotic  state  is  moreover  fre- 
cpiently  interpreted  as  the  cause  of  the  headaches,  which  seems 
to  me,  to  add  to  the  mental  difficulties  of  the  patient.  Not  in- 
frecpiently  they  tliink  themselves  "Jialf  crazy,"  (and  they  seem 
so). 

A  feature  that  comes  into  consideration  for  all  patients, 
is  not  only  a  satisfactory  anaesthesia  but  the  amount  of  cocaine 
necessary  to  obtain  it.  The  complete  operation  for  the  upper 
cells  extends  over  so  large  a  part  of  the  lateral  wall,  that 
anaesthesia  by  surface  painting  with  a  solution  of  sufficient 
strength  is  apt  to  be  followed  by  cocaine  ahsorption  to  such  a 
degree,  as  to  constitute  poisoning.  This  happens  by  virtue  of 
the  extent  of  surface  painted  and  the  amount  of  cocaine  used. 
In  order  to  obviate  this  difficulty,  I  l)egan  in  1913,^®  the  use  of 
a  nerve  trunk  anaesthesia,  which  requires  much  less  cocaine 
and  is  applied  over  a  much  smaller  area.  The  nerve  supply 
of  the  nose  in  great  part  is  from  the  nasal  ganglion  and  enters 
through  the  sphenopalatine  foramen.     The   remaining  supply 


HYPERPLASTIC    SPHEKOIDITIS  161 

is  the  internal  nasal  nerve  which  enters  tlirongh  the  longitndinal 
fissure  of  the  ethmoid  (Piersol,  Human  Anafomij,  1907,  page 
192,  line  6)  at  the  apex  of  the  angle  formed  by  the  roof  with 
the  anterior  limit  of  the  nose.  At  both  of  these  points  the 
nerves  may  l)e  1)locked  l)y  a  small  amount  of  strong  cocaine 
solution  applied  to  the  membrane.  For  this  purpose  I  set  a 
small  aluminum  applicator  which  carries  about  one  drop  of 
saturated  (90  per  cent)  water  solution  under  the  posterior  tip 
of  the  middle  turbinate,  and  leave  it  five  minutes  for  effect  on 
the  nasal  ganglion.  It  is  then  changed  to  rest  just  back  of 
the  tip  in  an  ui^ward  and  backward  direction,  to  lie  approxi- 
mately over  the  trunks  in  the  sphenopalatine  foramen  and  al- 
lowed to  remain  another  five  minutes.  I  do  this  because  the 
ganglion  anaesthesia  may  not  always  be  complete  in  five  min- 
utes. The  trunk  application  usually  completes  it.  I  have  also 
tried  both  of  these  positions  singly.  I  find  the  combination 
more  satisfactoiy.  At  the  time  the  posterior  applicator  is 
changed  at  the  end  of  the  first  five  minutes,  I  set  the  anterior 
applicator  for  the  internal  nasal  nerve.  I  use  a  toothpick-like 
wooden  stick  carrying  about  one-half  drop  of  the  same  solu- 
tion, using  the  anterior  limit  of  the  nose  as  a  guide,  j)assing  it 
upward  until  it  reaches  the  roof,  where  it  automatically  lodges 
in  the  apex  of  the  angle,  allowing  it  five  minutes  in  position. 
Anaesthesia  thus  secured  is  complete  and  comj)rehensive  for  the 
distribution  of  the  respective  nerves,  namely,  that  half  of  the 
nose.  I  have  repeatedly  had  patients  show  no  trace  of  cocaine 
disturbance,  and  tell  me  afterward  that  they  felt  no  pain  from 
the  complete  upper  cell  operation.  On  one  occasion  I  did  the. 
upper  and  antrum  operations  at  the  same  time  with  such  anaes- 
thesia. But  usually  I  have  not  found  the  indications  combined, 
necessitating  both  together. 

The  patient  at  the  time  of  operation  should  be  instructed 
that  he  will  have  three  things  to  engage  his  attention.  First, 
pain;  second,  the  noise  of  the  bone  cutting;  third,  the  pulling 
(force)  required  to  put  the  knife  through  the  tissues  (which 
often  is  great).  He  Avill  not  confuse  the  first  with  the  second 
and  third,  if  his  mind  be  directed  properly. 

No  anaesthsia  has  been  so  satisfactory  as  this,  (in  my  ex- 
perience)   and  cocaine  poisoning  has  been   almost   eliminated 


162  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

(in  my  experience)  by  its  nse.  All  cocaine  anaesthesia  may, 
however,  fail  sometimes  for  two  reasons.  Acutely  inflamed 
tissue  will  not  become  anaesthetic  by  cocaine,  nor  can  a  ter- 
rified patient  be  anaesthetized.  The  former  is  easier  to  under- 
stand. I  have  repeatedly  been  assured  by  the  most  intelligent 
but  terrified  patients  whom  I  have  operated  on,  despite  their 
mental  state,  with  what  Avas  a  superabundance  of  cocaine,  that 
the  pain  Avas  as  though  no  anaesthetic  had  been  used.  This 
has  been  true  for  all  methods  of  applying  cocaine.  This  is  not 
so  easily  understood.  Added  to  these  is  a  small  class  in  Avhom 
neither  terror  nor  local  inflammation  explains  the  resistance  of 
the  tissues  to  cocaine.  It  is,  hoAvever,  fortunatel}^  a  very  small 
class. 

An  application  of  adrenalin  solution  is  helpful  in  reducing 
swelling,  giAdng  a  Avider  field  of  operation,  as  Avell  as  control- 
ling bleeding,  and  possibly  helping  the  anaesthesia. 

The  Operative  Procedure 

Anatomically  the  paranasal  cells  are  designated  according 
to  Avhich  meatus  of  the  nose  they  enter.  This  is  more  or  less 
an  anterior  and  posterior  subdivision,  and  for  the  purposes 
of  diagnosis  this  must  remain  unchanged.  For  surgical  pur- 
poses, hoAvever,  it  seems  to  me  that  they  may  advantageously 
be  thought  of  as  upper  and  loAver,  the  latter  being  the  antrum 
of  Highmore,  the  former  being  the  remaining  cells.  This  sub- 
diAasion  establishes  a  horizontal  diA^ding  line  on  the  lateral 
Avail  at  about  its  middle.  Successful  surgery  of  the  antrum 
must  leave  a  drain  at  the  level  of  the  nasal  floor.  The  loAver- 
most  part  of  the  upper  cells  is  along  the  line  separating  them 
from  the  antrum ;  i.  e.,  the  horizontal  midline.  Successful  sur- 
gery of  the  upper  sinuses,  hoAvever,  is  not  achieA^ed  by  a  drain 
along  this  line,  for  the  reason  that  there  are  usually  cells  Avhich 
are  limited  to  a  part  far  aboA^e  the  midline.  Successful  sur- 
gery of  the  upper  sinuses  must  lay  open  for  drain  the  upper 
cells  in  their  entirety  beginning  at  or  very  close  to  the  crib- 
riform plate  of  the  ethmoid — the  roof  of  the  nose — opening  at 
the  same  time  the  loAvermost  of  these  cells,  that  is,  remoAdng 
the  lateral  Avail  Avith  the  middle  and  upper  turbinates  aboA^e  the 
midline. 


HYPERPLASTIC    SPHENOIDITIS  163" 

This  procedure  may  be  conservative  or  radical.  The  for- 
mer consists  of  the  removal  of  the  turbinate  and  the  very  super- 
ficial nasal  laj^er  of  the  capsule  of  the  ethmoid.  The  radical 
operation  consists  of  removing  the  capsule  ^'part  and  parcel" 
including  the  orbital  plate  Avhen  desirable  for  drainage  of  the 
orbit  into  the  nose,  at  any  or  all  points  from  its  anterior  limit 
to  its  apex. 

One  comprehensive  surgical  procedure  has  been  offered  for 
this  district.  To  this  therapeutical  end  particularly  was  di- 
rected the  intelligence  of  Dr.  H.  P.  Mosher"'*  when  he  proposed 
the  "Surgery  of  the  Ethmoidal  Labyrinth."  That  procedure 
must  of  necessity  be  a  radical  one,  although  he  does  not  recom- 
mend it  for  the  extreme  of  radical ;  to  wit,— opening  the  orbit. 
He  proposed  it  for  the  relief  of  cases  in  advanced  stages  of 
suppuration  and  degeneration,  not  such  cases  as  I  have  delin- 
eated. It  is  admirable  for  the  cases  he  proposed  it  for.  The 
procedure  reconunended  by  Dr.  Otto  Freer,-°  in  which  he  pro- 
poses to  enter  the  frontal  sinus  by  way  of  the  bulla  ethmoidalis, 
seems  to  me  to  be  based  on  a  Avrong  conception  of  surgery  and 
insufficient  knowledge  of  the  anatomy  of  tlie  parts.  It  is  also 
fraught  with  the  danger  of  upward  and  backward  and  down- 
ward and  backward  cutting  without  a  guide  and  should  be  con- 
demned. 

It  seems  to  me  that  the  procedure  that  I  now  submit  has 
some  advantages  that  are  not  otherwise  offered.  It  has  been 
satisfactory  in  my  hands  for  ten  years.  It  may  be  limited  for 
the  frontal  sinus,  providing  a  very  high  cut  of  the  middle  tur- 
binate which  I  have  frequently  mentioned  in  various  texts  as  a 
''cribriform  or  infundi])ulum  turlnnectomy. "  The  cut  is  actu- 
ally 2  or  2.5  mm.  from  the  ci'ibriform  plate  and  may  be  ex- 
tended to  the  most  anterior  limit  of  the  infundil^ulum.  Or  this 
very  high  cut  may  be  carried  backward  to  include  the  capsule 
of  the  ethmoid,  under  which  condition  not  only  is  the  middle 
turbinate  removed,  but  the  uppermost  line  of,  and  usually  all 
the  other  ethmoidal  cells  are  opened  wide  into  tlie  nasal  cavity. 
And  when  desirable  the  entire  anterior  wall  of  the  body  of  the 
sphenoid  from  its  uppermost  limits,  \\ith  all  its  post-ethmoidal 
association  and  much  of  its  jloor  may  be  removed.  In  my  judg- 
ment and  experience  it  is  the  technique  tliat  most  often  may 


164  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

be  trusted  to  open  all  of  the  cells,  regardless  of  iinvsual  or 
anomalous  positions.  It  accomplishes  the  frontal  inlet  as  Dr. 
Freer  endeavors  but  by  safe  cutting.  I  know,  lioivever,  that 
cells  may  exist  that  not  onhj  cannot  he  opened  from,  the  nose 
hut  cannot  he  located  hy  any  means  at  present  at  our  command. 
They  can  only  be  recognized  in  the  cadaver  and  then  only  by 
complete  dissection.  Everyone  who  has  observed  a  reasonable 
number  of  specimens  has  seen  such  cells  and  been  struck  by 
the  futility  that  Avould  attend  any  sui'gical  effort  to  reach  them ; 
and  everyone  of  reasonably  wide  experience  has  met  cases 
where  all  efforts  had  failed  to  find  and  treat  such  cells.  But 
there  are  many  other  cells  that  are  placed  in  positions  more  or 
less  unusual  that  will  be  opened  by  a  technique  which  has  for 
its  primary  plan  an  incision  icliich  will  shirt  the  crihriform 
plate  and  remove  the  ethmoidal  u:all  and  the  middle  turhinate 
at  its  most  anterior  as  ivell  as  its  most  upper  limits  and  extend 
into  the  sphenoid  hody  at  its  uppermost  part  regardless  of  the 
natural  opening,  and.  then  he  extended  doivmvard  until  it  has 
cut  through  its  floor  or  found  it  to  he  impenetrable.  I  have 
avoided  the  designation  of  sphenoid  sinus  because  such  a  term 
does  not  always  comprehend  the  full  body  of  the  sphenoid.  It 
(the  body)  may  be  subdivided,  and  shared  l)y  a  post-ethmoidal 
cell.  And  it  is  this  variation  which  I  believe  to  be  the  most  per- 
nicious from  the  clinical  side  (for  headache  and  optic  nerve  le- 
sions), as  Avell  as  anatomically  far  more  frequent  than  is  at 
present  recognized  clinically.  This  variation  will  (it  seems  to 
me)  be  satisfactorily  dealt  with  by  this  proposed  technique 
practically  every  time  it  is  met.  Also  pre-frontal-ethmoidcd 
cells  will  be  opened  into  the  nose  as  a  rule,  if  not  uniformly. 
Technique. — In  1907  I""  puljlished  an  elementary  text  in 
Avhich  I  described  a  surgical  method  which  was  at  that  time 
novel.  It  consisted  in  approaching  the  turbinate  from  above 
on  its  inner  side.  Prior  to  that  all  surgical  approach  was  from 
below  laterally  upward,  removing  it  by  scissors  or  snare  or  a 
combination  of  these  or  such  working  instruments.  I  at  the 
time  described  a  knife  consisting  of  a  handle,  a  shaft  and  a  cut- 
ting end  turned  at  a  right  angle  to  the  shaft  and  sharpened  so 
as  to  cut  on  the  inside  of  the  right  angle ;  i.  e.,  on  the  imll.  It 
was  also  sharpened  on  a  face  parallel  to  the  shaft  which  at 


HYPERPLASTIC    SPHEXOIDITIS 


165 


the  same  time  gave  it  far  more  strength  than  a  hook  could  have 
were  it  sharpened  on  its  concavity.  I  selected  this  shape  in 
preference  to  a  hook  for  those  reasons,  and  the  fact  that  great 
strength  is  necessary  for  the  tasks  to  which  this  knife  is  put. 
The  knife,  although  p)ossessing  great  strength  is  so  small  that 


Fig.  85. — On  the  right  the  angle  knife  is  shown  in  the  sagittal  plane  ready  for  inser- 
tion under  the  middle  turbinate.  On  the  left  it  is  shown  in  position  for  the  forward  and  down- 
ward cut.  It  has  been  introduced  into  the  infundibulum  and  rotated  30  degrees  inwards,  i.  e., 
toward  the  septum  nasi.  The  heavy  line  A-B  shows  diagrammatically  the  line  of  this  first  cut 
which  may  be  accomplished  in  one  stroke  or  two,  according  to  the  surgeon's  election  (I  pre- 
fer two  strokes  usually.) 


it  may  readily  enter  spaces  which  larger  instruments  could  not. 
I  believe  it  to  he  the  smallest  nasal  instrument  possessing  great 
strength. 

A  glance  at  the  lateral  wall  sliov/s  that  the  higher  and 


166  HEADACHE.S    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN" 

the  more  forward  the  infnndilnihun  is  opened  the  wider  and 
freer  will  be  the  inlet  to  the  frontal  sinus  usually.  At  the 
same  time  pre-frontal  ethmoidal  cells  will  usually  he  opened 
by  such  an  incision.  For  these  reasons  it  has  been  advanta- 
geous, in  my  hands,  to  introduce  the  knife  sagittal  under  the 
anterior  third  of  the  middle  turbinate  as  far  back  as  the  un- 
cinate process,  as  high  as  the  cribriform  plate  Avith  its  cut- 
ting edges  facing  forward.  It  is  then  rotated  somewhat  in- 
ward and  drawn  forward  and  doAvnward.  Fig  85.  Consider- 
able forward  pressure  is  kept  on  it  while  it  is  being  drawn  down- 
ward. In  this  way  the  foremost  and  uppermost  nasal  wall  of  the 
capsule  of  the  ethmoid  (with  the  attachment  of  the  middle  tur- 
binate) is  cut  open,  and  the  pre-frontal  cells  of  the  ethmoid  are 
thereby  thrown  open,  as  the  nasal  wall  of  these  cells  is  usually 
constituted  by  that  part  of  the  capsule,  with  the  attachment  of  the 
turbinate.  This  nmst  be  considered  the  conservative  technique. 
By  these  means,  however,  are  put  an  inlet  or  outlet  to  the  usual 
frontal  sinus  that  comprehends  the  dimensions  of  the  usual 
infundibulum;  i.e.,  1  cm.  anteroposteriorly  and  0.50  cm.  later- 
ally. Should  this  size  be  reduced  to  such  a  degree  as  to  require 
some  procedure  more  radical,  the  knife  is  then  engaged  in  the 
hiatus  semilunaris  with  its  cutting  edges  forward  or  down- 
ward— usually  in  the  uppermost  limit.  By  a  downward  pull, 
the  uncinate  process  will  be  removed,  and  the  knife  may  finally 
be  engaged  in  the  floor  of  the  anterior  part  of  the  frontal  sinus. 
(Fig.  99.)  This  may  be  so  thick  and  hard  that  it  is  with  diffi- 
culty, or  impossibly,  handled  by  this  knife.  A  large  enough 
opening,  however,  is  usually  secured  to  admit  a  Good  rasp  or 
a  burr.  The  burr  is  then  introduced  into  the  sinus  and  put  in 
motion  with  a  forward  and  downward  pull.  In  this  way  I  have 
slightly  modified  Ingals'-^-  ideal  frontal  sinus  technicpie.  This 
stroke  of  the  right-angle  knife,  it  will  be  seen,  is  safe,  as  it  cuts 
away  from  danger  (brain),  or  the  knife  in  position,  cutting 
edges  facing  upward  and  forward  is  likewise  safe  with  a  down- 
ward or  forw^ard  pull,  as  it  also  cuts  away  from  danger.  It  will 
cut  into  the  Imttress  of  the  lower  anterior  part  of  the  sinus. 
For  the  anterior  ethmoidal  district  the  knife  is  reintro- 
duced along  the  cribriform  plate — its  smooth  elbow  with  a  gen- 
tle touch,  recognizing  the  smooth  uppermost  limit  of  the  nose — 


HYPERPLASTIC    SPHENOIDITIS 


167 


X'"' 


Fig.  86. — Shows  the  angle  knife  introduced  between  the  septum  and  middle  turbinate. 
It  has  passed  1  cm.  back  of  the  first  cut  along  the  cribriform  plate.  The  dotted  line  X  shows 
it  to  have  been  rotated  outward  until  its  cutting  edges  point  30  degrees  above  the  hoTizontal. 
The  tip  of  the  nose  has,  at  the  same  time,  been  forcibly  elevated.  The  heavy  dotted  line  A-B 
shows  the  line   of  cut. 


to  a  distance  1  cm.  In  this  position  its  two  cutting  edges  face 
downward.  It  is  now  rotated  until  its  cutting  edges  point  out- 
ward and  slightly  upward.  The  upward  turn  is  added  to  the 
outward  for  the  reason  that  the  outward  and  upward  position 


168 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


permits  of  a  more  nearly  horizontal  pull.  The  slight  upward 
turn  keeps  the  line  of  incision  much  more  nearly  the  horizontal 
despite  the  fact  that  the  pull  must  needs  he  downward  and  for- 
ward or  forward  and  downward.    The  safety  of  this  cut  is  pro- 


■X 


Fig.  87. — Same   as   Fig.   86,   with  the   difference  that   the   knife   has   been  passed   the   second   time 
along   the  cribriform   plate   to   a   distance   1    cm.    back   of   the  first   cut. 

vided  by  two  factors,  i.  e.,  the  cells  of  the  ethmoid  in  their 
extension  into  the  roof  of  the  orhit  rise  at  once  above  the  crib- 
riform plate;  and  the  length  of  the  cutting  arm  of  the  knife 


HYPERPLASTIC    SPHEXOIDITIS 


169 


Avliicli  should  be  2  mm.  is  too  short  to  cut  through  the  thickness 
of  the  nasal  orbital  tliickness  of  the  ethmoid  capsule  under  any 
circumstances.  This  incision  is  the  first  of  two  or  three  sim- 
ilar ones.     (Figs.  86  and  87.)     I  prefer  to  divide  it  into  two 


Fig.   88. — Shows    the   knife    introduced    sagitally   under  (lateral    to)    thei   middle   turbinate 

for   the   purpose   of   cutting   into   the   capsule   of    the   ethmoid.  The    dotted   line   1-J-3   shows   the 

successive    cuts    from    above    downward.      These    cuts    may    be  readily    made    to    enter    the    orbit 

by  inclining  the  cutting  edges  30  degrees  outward.  In  the  conservative  employment  of  this 
technic,    this    employment   of   the    knife    may   be    omitted. 

or  three  because  I  can  keep  my  bearing  upon  the  cribriform 
plate  more  satisfactorily  by  these  shorter  cuts  than  in  one  longer 
one. 


170 


HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN" 


Now  the  operative  iDi'oeedure  is  to  be  directed  by  the  judg- 
ment of  tlie  surgeon.  In  my  judgment  the  only  turbinectomy 
should  be  a  cribriform  or  infundibular  turbinectomy^;  i.e.,  one 
that  opens  the  infimdibulum  to  its  widest  possibilities,  for  the 
reason  that  a  lower  cut  leaves  a  stump  that  is  physiologically 
worthless  and  surgically  difficult  of  later  manipulation.  This 
is  not  in  reality  a  stump  although  in  former  years  I  considered 
it  such."^  It  is  that  part  of  the  ethmoidal  capsule  which  makes 
the  inner  portion  of  the  final  entrance  of  the  frontal  sinus  into 
the  nose — the  anterior  part  l)eing  the  uncinate  process,  the  pos- 
terior part  being  the  bulla  ethmoidalis,  the  external  and  inter- 
nal parts  being  ethmoid  capsule.     The  removal  of  this  inner 


Fig.   89. — Shows  the  snare  loo]!  placed  arouiid  part  detached. 

part  as  high  as  possible  usually  gives  an  inlet  to  the  frontal 
sinus  G  nmi.  anteroposteriorly  by  3  mm,  laterally.  Some  fron- 
tals  enter  the  nose  by  a  devious  ch.annel  and  cannot  be  consid- 
ered as  usual  (Figs.  14,  15,  16,  and  17,  page  37).  If  this  upper 
internal  part  of  the  frontal  inlet  be  not  removed  at  the  primary 
operation  it  seems  to  me  to  be  unfortunate,  as  a  secondary  opera- 
tion will  almost  surely  wound  the  epithelial  surfaces  of  the 
frontal  inlet  and  then  be  followed  by  connective  tissue  develop- 
ment whicli  will  l)lock  the  inlet.  The  primary  high  cut  is  usually 
accomplished  without. that  result,  leaving  the  hiatus  semilunaris 
and  infundibulum  free  of  scar  tissue.  The  secondary  operation 
is  usuallv  of  necessitv  done  with  more  trauma  to  the  hiatus 


HYPERPLASTIC    SPHENOIDITIS 


171 


regardless  of  whatever  technique  is  employed.  For  this  reason 
I  emphasize  the  advisability  of  doing  the  foremost  cribriform 
cut  primarily  if  the  anterior  half  of  the  turbinate  is  touched  at 
all,  regardless  of  whatever  else  is  to  be  done  surgically.  (Com- 
pare Fig.  90.) 

The  cutting  edges  of  the  introduced  knife  are  now  turned 
do^\Tiward  or  downward  and  slightly  outward  (Fig.  88),  and 
the  incision  is  placed  superficial  (internally)  or  may  be  placed 
as  deep  (externally)  in  the  capsule  of  the  ethmoid  as  the  judg- 
ment of  the  surgeon  directs.  For  the  simplest  subacute  sup- 
purative cases,  the  superficial  incision  suffices.     For  most  rad- 


Fig.   90. — Showing  the   line   1-2-;^  of  amputation   of   the  ))enduIous   middle   turbinate.      No    ethmoid 
cells    are    opened    by    this    procedure    nor    is    the    infundibulum    opened. 

ical,  e.  g.,  an  orbital  phlegmon  l)ack  of  the  transverse  meridian 
of  the  eye,  the  incision  goes  through  the  capsule  into  the  orbit 
in  its  posterior  half.  This  is  readily  and  quickly  done.  The 
detached  mass  is  then  by  means  of  the  same  knife,  which  may 
be  turned  somewhat  transverse,  pushed  do^mward  into  the  nose 
where  a  snare  may  be  put  around  it  and  cut  it  from  its  attach- 
ments (Fig.  89).   ^ 

The  procedure  may  b(^  varied  l)y  a  superficial  removal  of 
the  turbinate  and  then  the  excision  of  the  capsule  to  any  extent 
desired.    In  my  practice  I  have  liad  twenty-two  orbitals  phleg- 


172 


HEADACHES    AND    EYE    DTSORDEKS    OE    NASAL    OEIGIN 


mons,  produced  by  nasal  sinus  ruptures,  twelve  of  which  I 
opened  into  the  nose  in  this  way  back  of  the  transverse  merid- 
ian.    In  my  experience  this  has  far  surpassed  the  results  of 


Fig:.  91. — Shows  knife  /  passed  backward  along  criliriform  plate  penetrating  anterior  face 
of  sphenoid  at  its  top.  The  dotted  lines  2  and  5  show  knife  passed  back  to  posterior  wall  of 
cell    and    to    have    been    rotated    20   degrees    inward    cutting   downward    to    hug   the    septum    nasi. 

external  orbital  drainage  inasmuch  as  it  drains  by  the  same 
route  that  infected  the  orbit. 

Should  the  sphenoidal  and  post-ethmoidal  cells  also  need 


HYPERPLASTIC    SPHEXOIDITIS 


173 


the  surgeon's  care,  I  then  (after  the  snare  amputation  of  the 
middle  turbinate)  pass  the  angular  knife  very  gently  backward 
along  the  cribriform  plate  with  its  cutting  edges  do^^'nward.  In 
this  Avay  its  smooth,  round  elbow  glides  along  the  cribriform 
plate  imtil  it  meets  the  anterior  face  of  the  body  of  the  sphenoid. 
This,  it  will  be  seen,  is  the  uppermost  point  of  the  face  and  is 


Fig.  92. — Shows  knife  to  have  been  reintroduced  through  uppermost  part  of  sphenoidal 
cut  as  shown  in  Fig.  91  to  posterior  wall  of  cell.  It  is  then  rotated  30  degrees  outvyard  (X) 
and  carefully  drawn  forward  and  (necessarily)  downward.  The  introduction  of  the  knife  to  the 
posterior  wall  of  the  cell  at  its  uppermost  part  insures  the  opening'  of  many  of  the  post-ethmoid 
cells  that  are  developed  into  the  sphenoid  body.  I  believe  this  to  be  very  important  and  one 
of  the  advantages  to  be  secured  by  this  technic. 

independent  of  the  natural  opening  of  the  sphenoid  sinus  which 
is  usually  Avell  below  this  point.  Gentle  pressure  is  now  made 
on  the  face  of  the  sphenoid  and  the  knife  inclined  slightly  to- 
ward the  septum.     The  first  stroke  perforates  the  usual  sphe- 


174 


HEADACHES    AND    EYE    DISORDERS    OF    XASAL    ORIGUST 


iioidal  face  and  cuts  somewhat  downward.  The  knife,  cutting- 
edges  dowaiward,  is  then  introduced  very  gently  into  the  open- 
ing SO  made  and  very  gentlj^  extended  as  far  back  as  the  cell 
permits.  It  is  rotated  15  degrees  inward,  and  draAvn  downward 
and  forward  with  any  degree  of  force  that  may  he  needed.  This 
incision  will  extend  from  the  junction  of  the  cribriform  plate 
with  the  body  of  the  sphenoid  downward,  a  varying  distance 
along  the  septum  nasi  depending  on  the  thickness  and  hardness 


Fig.  93. — Shows  the  Kniglit  forceps  ("made  es]iecially  for  this  purpose  3  cm.  longer  than 
the  original  model  because  this  added  length  is  often  required)  introduced  into  the  opening  in 
the  anterior  face  of  the  sphenoid  body  ready  to  bite  out  the  anterior  half  of  the  floor  of  the 
body.  This  is  oftentimes  easily  done,  but  at  other  times  the  floor  is  too  thick  to  be  removed  this 
way.     It  is  removed  by  a   rotatory   movement. 


of  the  bone.'  Should  this  incision  not  have  reached  the  floor  of 
the  sphenoid,  another  similar  one  usually  does  (Fig.  91).  Then 
the  knife,  edges  dow^i,  is  again  passed  along  the  cribriform 
plate  and  very  carefully  introduced  back  into  the  uppermost 
limit  of  the  opening  already  made.  It  is  then  rotated  30  de- 
grees outward  and  brought  out,  forward  and  downward  (Fig. 


HYPERPLASTIC    SPHEXOIDITIS 


175 


92).  This  incision  includes  a  considerable  part  of  the  wall 
separating  the  post-ethraoidal  from  the  sphenoidal  cell,  and  it 
has  the  advantage  of  beginning  at  the  uppermost  limit  of  the 
sphenoidal  face.  It  has  a  distinct  advantage  over  all  methods 
which  begin  their  procedure  in  or  from  the  natural  opening  of 
the  sphenoid,  for  the  reason  that  often  a  post-ethmoidal  cell 
occupies  a  part  of  the  body  of  the  sphenoid  and  is  placed  above 
the  sphenoidal  cell.  Fig.  100  shows  such  a  cell  which  would  be 
opened  by  this  technicpie  and  would  probably  not  be  opened  by 
any  other  technique  now  known.  Such  cells  are  exceedingly 
hard  to  deal  with  surgically  and  sometimes  equally  hard  or 


Fig.   94. — Shows    the    Knight    forceps    in    position   to    bite    out    the    post-ethmoidal   wall    which    has 
been   cut   loose,   as   shown   in   Fig.    92. 

impossible  to  find.  Fig.  101  shows  such  a  cell  placed  all  above 
the  line  of  the  cribriform  plate.  This  cell  would  not  be  opened 
by  this  technique  and  I  do  not  believe  it  could  be  recognized  in 
life  by  the  present  means  of  investigation.  Some  such  cells, 
however,  have  a  lateral  and  downward  extension  which  is 
opened  by  the  second  stroke  of  the  knife  which  is  again  intro- 
duced along  the  cribriform  jjlate  and  inserted  into  the  cavity 
in  the  body  of  the  sphenoid,  turned  30  degrees  outward  and 
dra^Mi  forward  and  downward.  This  second  cut  usually  takes 
the  post-ethmoidal  nasal  wall  as  well  as  most  of  the  lateral  part 
of  the  sphenoidal  face  and  often  the  mass  may  be  removed  in 


176 


HEADACHES    AND    EYE    DISORDERS    OF    ISTASAL    ORIGIN" 


one  piece.  For  this  purpose  I  use  the  Knight  forceps  (Figs.  94 
and  95),  made,  however,  for  this  particular  purpose,  being  2.5 
cm.  longer  than  the  original  model.  These  forceps  are  then 
introduced  into  the  cavity  of  the  sphenoid  (Fig.  93),  and  so 
the  floor  of  the  sphenoid  is  removed  in  part.  Everyone  knows, 
however,  that  the  floor  often  is  so  thick  and  hard  that  it  cannot 
be  removed  by  forceps.  A  drill  which  a\  ill  do  such  service  may 
be  advantageous.  Fig.  97  shows  a  special  post-ethmoidal  forceps 
which  is  often  of  service. 

In  the  performance  of  the  post-ethmoidal-sphenoidal  por- 
tion of  the  technique  I  prefer  a  knife  smaller  and  slightly  dif- 


Fig.   95, 


-Shows   post-ethmoidal    walli  in    grasp    of   forceps.      It   is    finally    detached   by    a    rotatory 

movement. 


ferent  from  that  used  in  the  anterior  portion,  for  the  reasons, 
first,  that  it  is  thereby  rendered  much  stronger;  it  cannot  be 
broken  in  any  of  the  service  it  may  be  put  into ;  and  secondly, 
a  knife  1.5  mm.  inside  cutting  edge  cannot  inadvertently  cut 
into  orbit  in  this  service  unless  wielded  by  some  one  neglecting 
the  proper  performance  of  the  operation  and  totally  ignorant 
of  the  anatomy  here;  and  thirdly,  I  feel  that  the  angle  of  the 
sphenoid  knife  should  not  have  turned  the  full  90  degrees  from 
the  shaft  because  such  a  knife  could  not  be  engaged  in  the  face 
of  the  sphenoid.  An  angle  of  68  degrees  off  the  shaft  which 
will  make  the  cutting  edge  on  the  inside  of  the  angle  112  degrees 


HYPERPLASTIC    SPHEXOIDITIS 


177 


will  bite  readily  into  the  face;  and  foiirtlily,  a  small  knife 
2.5  mm.  in  its  entire  cross  measurement  permits  a  much  closer 
approach  to  the  top  of  the  sphenoid  face.  One  6  mm.  could  not 
get  so  close  by  3.5  mm.  In  this  service  a  hook  sharpened  on  its 
concavity  would  be  much  less  advantageous  because,  if  bent 
to  a  right  angle,  it  would  not  bite  into  the  face  and  if  in  68  de- 
grees to  112  degrees  shape  it  would  not  execute  the  work  so  Avell 
and  its  point  would  break  easily,  when  it  would  take  the  shape 
of  the  knife  now  proposed  without  being  sharpened. 

I  feel  that  special  emphasis  should  be  laid  upon  the  neces- 


Fig.  96. — Shows  a  three-quarter  view  of  specimen  with  operation  completed.  The  an- 
terior half  has  been  left  "conservative,"  i.  e.,  the  wall  is  intact  with  all  the  openings  free  as 
far  as  1.5  mm.  of  the  criljriform  plate.  An  infundibular  cell.  A,  has  been  opened  as  shown 
first  in  Fig.  89.  The  posterior  half  is  "radical,"  i.e.,  the  anterior  wall  of  the  sjihenoid  cell  has 
been  removed  witn  its  entire  post-ethmoidal  part  (lateral  part,  which  is  one-half  or  two-thirds 
of  its  extent).  The  post-ethmoidal  cells  have  of  necessity  been  dealt  with  radically  to  accom- 
plish this,  i.  e.,  their  entire  nasal  side  has  been  removed.  Bristle  B  is  shown  passing  from  the 
nose  into  the  frontal  sinus.  Bristle  C  is  shown  passing  through  the  post-ethmoidal-sphenoidal 
opening.  A  strip  of  bone  D  has  been  left  to  indicate  the  position  of  the  sphenoidal-vomer 
junction. 


sity  of  the  surgeon  knowing  what  are  the  correct  models  of 
these  knives.  For  this  reason  I  submit  dimensions  and  draw- 
ings (Fig.  98^  and  B).  Too  large  a  knife  has  the  disadvantage 
(1)  of  taking  up  space  unnecessarily,  and  of  (2)  biting  more 
bone  than  it  can  cut,  and  (3)  of  possibly  cutting  inadvertently 
into  the  orbit,  and  (4)  of  being  nmcli  more  apt  to  have  its 
angle  cutting  portion  broken  otf  in  the  operation.    In  this  con- 


178 


HEADACHES    AND    EYE    DTSORDERS    OF    NASAL    ORIGIN 


nection  it  must  be  empliasized  that  it  is  absolutely  necessary 
that  the  knife  be  tempered  not  too  hard.  Should  it  be  too  hard 
it  will  always  break  with  the  work  put  on  it  in  this  operation. 
The  instrument  maker  must  specially  understand  this.  It  is 
far  better  to  have  it  too  soft.  As  such  its  cutting  edges  may  not 
be  as  lasting,  but  it  will  not  break. 

Summary. — The  intranasal  surgery  of  tlie  upper  cells  may 


Fig.  97. — A  three-quarter  view  of  a  post-ethmoidal  forceps  made  right  and  left.* 

be  performed  by  this  method  in  any  part  or  the  Avhole  as  con- 
servatively or  as  radically  as  desired.  The  ability  to  place  the 
incision  safely  2  mm.  below  the  cribriform  i)late  in  any  part  of 
or  in  the  whole  length  of  its  extent  seems  to  me  to  be  most  ad- 
vantageous, and  not  a  small  part  of  this  advantage  is  the  power 


n 


K^ 


Fig.    98. — A.    Sphenoid    knife.*      B.    Turbinate    knife.*      C  and   D.    Turbinate   knives*   made   right 
and  left.     Some  of  my  confreres  prefer  right  and  left  knives.     I   prefer  the  straight  knife. 

to  extend  this  incision  to  the  foremost  limit  of  the  infundibulum, 
thereby  opening  the  inlet  of  the  frontal  to  its  Avidest  natural 
jDossibilities.  It  is  most  desirable  to  preserve  the  natural  inlet 
here,  and  this  is  done  by  a  cribriform  turbinectomy  which  leaves 
undisturbed  the  histologic  epithelial  covering  of  the  normal 
inlet ;  i.  e.,  the  uncinate  process,  the  bulla  ethmoidalis,  the  hiatus 
semilunaris   and   infundibulum,   regardless   of   the   anatomical 


*To  be   had   of  V.   Mueller   &   Co.,   Chicago,   111. 


HYPERPLASTIC    SPHENOIDITIS 


179 


variations  of  the  frontal  inlet.  Should  these  parts  be  wounded, 
as  in  a  cnrettement,  the  resultant  scar  tissue  blocks  the  inlet. 
The  angle  knife  removes  by  cutting  any  desired  tissue  with  the 
least  possible  trauma  to  the  surroundings.  In  the  sphenoidal 
district  it  opens  the  uppermost  and  loicerniost  possible  parts 
of  the  face  which  has  the  advantage  sometimes  of  opening  also 
a  post-etlimoidal  cell  Avliich  may  occupy  part  of  the  body  of 
the  sphenoid.  (Such  a  cell  is  often  the  cause  of  the  entire  clin- 
ical picture.)     The  angle  knife  is  so  small  that  it  takes  up  the 


Fig.  99. — Shows  the  knife  in  position  for  cutting  away  the  uncinate  process  preparatory 
to  Ingals'  removal  of  the  frontal  sinus  floor.  Oftentimes  the  entire  frontal  floor  may  be  cut 
away  by  the  knife. 


minimum  room  and  so  leaves  the  small  field  open  to  the  best 
vision  possible.  Its  execution  is  always  in  the  direction  away 
from  the  (brain)  danger  zone.  I  have  so  far  not  seen  such  sat- 
isfactory post-ethmoidal  surgery  by  other  methods.  (This  dis- 
trict seems  to  me  the  most  dangerous  of  all,  for  on  the  outer 
upper  aspect  runs  the  optic  nerve  and  above  is  the  optic  chiasm 
and  cranial  cavity.)  Satisfactory  execution  is  necessary,  par- 
ticularly for  eye  lesions. 

This   entire  performance  may  be   accomplished  Avithin   a 
short  time.     I  have  often  finished  the  high  frontal  ethmoidal 


180 


HEADACHES    AISTD    EYE    DISORDERS    OF    N^ASAL    ORIGIN 


and  splienoidal  combined  operation  in  two  minutes   (including 
the  post-orbital  opening  on  one  occasion). 

A  septum  nasi  deflected  into  the  affected  side  may  add 
troubles  for  the  surgeon.  I  have  in  such  cases  where  the  mid- 
dle turlnnate  was  not  visible  from  in  front  in  any  loart  used  a 
bi-valve  speculum  specially  constructed  for  the  purpose.  Just 
as  Killian  elongated  the  blades  of  the  primary  bi-valve  for  his 
needs  in  septum  resection,  I  have  elongated  them  still  more 


Fig.  100. — Shows  knife  approaching*  a  post-ethmoidal  cell  which  lies  on  the  top  of  the 
sphenoidal  sinus  and  occupies  about  one-half  of  the  body  of  the  sphenoid.  The  line  A  shows 
position  of  approach.  B  shows  the  position  for  cutting.  From  considerable  clinical  experience 
I  believe   this  cell   would  be   opened  by   this  technique. 


and  widened  them  for  my  needs  here  (Fig.  103).  Tlie  speculum 
should  be  made  of  tempered  steel  l)lades,  knife-like  thin,  Avith 
handles  long  enough  to  give  leverage  to  dislocate  the  entire 
septum  into  the  opposite  nostril.  It  should  have  a  set  screw, 
for  the  pressure  required  is  much  and  the  hand  gets  tired  hold- 
ing it.  Its  blades  should  l)e  9  mm,  wide,  for  narrower  ones  such 
as  are  supplied  witli  Killian 's  often  do  not  give  sufficient  view. 


HYPERPLASTIC    SPHEXOIDITIS 


181 


r^t.^v-'Cf 


Fig  10]  — A  shows  the  usual  sphenoidal  sinus  and  the  usual  cribriform  plate 
usual  relations.  B  shows  post-ethmoidal  ceil  /  placed  altogether  on  top  of  sphenoid 
Its  lowermost  limit  is  almost  on  the  horizont'al  of  the  cribriform  plate  3.  This  cell 
have  been  opened  by  this  technic,  nor,  in  my  judgment,  by  any  other  extent. 


with   their 

al    sinus   3. 

could   not 


182 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


They  should  be  88  mm.  long,  for  shorter  ones  (Killian's)  some- 
times fail  to  reach  the  posterior  field  of  operation.  Killian's 
short  blades  are  advantageous  for  the  anterior  district. 

The  knives  are  also  made  right  and  left   (Fig.  98  C-D). 


Fig.  102. — Showing  the  left  half  of  specimen,  i,  right  sphenoidal  sinus  extending  into 
left  side  to  border  left  optic  canal  s.  A  post-ethmoidal  cell  4  also  borders  left  optic  canal.  All 
three  of  these  cells  would  probably  have  been  opened  by  this  technic  operating  on  the  left  side. 


Some  of  my  associates  prefer  these.  My  own  preference  is  for 
the  single,  straight,  original  model.  I  recommend  an  extra 
(2.5  cm.)  long  shaft  for  use  with  the  long  blade  sphenoidal  spec- 


Fig.  103. — Sphenoidal  speculum.*  It  is  the  primary  bivalve  nasal  speculum  made  of  tem- 
pered steel  blades  88  mm.  long  9  mm.,  wide,  knife  edge  thin  near  tip.  It  should  have  a  set 
screw.  It  is  a  simple  enlargement  of  the  primary  bivalve  for  this  purpose  as  Killian's  enlarge- 
ment is  for  the  purposes  of  septum  resection.  It  is  13  mm.  longer  and  4  mm.  wider  than  the 
usual  model  of  Killian's.  The  sphenoidal  knife  used  with  this  si)eculum  is  25  mm.  longer  than 
the  regular  knife.  By  means  of  this  speculum  the  route  to  the  sphenoid  may  be  forcibly 
widened  when  it  is  too   narrow. 

*To  be  had  of  V.  Mueller  &  Co.,  Chicago,   111. 


HYPERPLASTIC    SPHENOIDITIS 


183 


ulnm.  A  strong,  large  handle  ought  always  be  supplied  for  the 
knife. 

A  right-hand  surgeon  makes  his  turbinate  cuts  for  the  left 
side,  cutting  edges  in  the  plane  of  the  handle.  For  the  right 
side  the  cutting  edges  are  turned  one  quarter  (90  degrees)  into 
right  nostril.  This  makes  them  horizontal  or  transverse  when 
the  handle  is  on  the  middle  line. 

This  technique  is  especially  advantageous  in  tall  noses. 
Some  measure  onlv  5  cm.  from  roof  to  floor,  others  measure 


Fig.   104. 


7.5  cm.  Figs.  104  and  105  represent  these  proportional  differ- 
ences. High  operating  in  the  former  is  much  simpler  than  in 
the  latter.  A  technique  which  cuts  downward  and  outward  is 
obviously  advantageous. 

The  lower  the  sphenoidal  post-ethmoidal  cut  goes  on  the 
lateral  wall,  the  more  likely  is  brisk  bleeding  and  shock  because 
this  incision  approaches  or  reaches  the  entrance  of  the  vessels 
and  nerves  as  they  come  through  the  sphenopalatine  foramen. 
The  bleeding  is,  however,  usually  slight  at  the  time  of  operat- 
ing, being  controlled  partly  by  adrenaline  solution  and  often  by 
the  lowered  blood  pressure  of  shock  which  increases  as  the 
larger  nerve-trunks  are  cut.    A  normal  blood  clot  then  has  time 


184 


HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 


to  form  and  close  the  vessels.  It  is  advaiitageons  to  avoid 
packing  the  nose  here  because  of  great  discomfort  of  a  pack  put 
ill  tight  enough  to  answer,  and  because  of  the  trauma  it  inflicts. 
Apposing  surfaces  are  roughened  and  later  s^aiechias  form.  In 
patients  with  scant  general  strength,  the  pack  that  should  usu- 
ally remain  48  hours  exhausts  them  more  than  the  shock  of  the 
operation.     This  may  be  prevented  largely  by  carbolizing  the 


Fig.   105. 


nasal  ganglion  before  the  operation,'*'  but  as  a  rule  of  practice 
I  prefer  to  put  the  patient  (without  pack)  in  a  hospital  for 
24  to  72  hours,  and  not  pack  unless  brisk  bleeding  develops. 
Should  it  come  on  it  is  usually  of  such  volume  as  to  require  im- 
mediate control.  If  the  patient  cannot  be  placed  in  a  satis- 
factory hospital,  I  always  pack  the  post-ethmoidal-sphenoidal 
district.  Small  doses  of  heroine  prevent  sneezing  and  so  elim- 
inate one  factor  that  brings  on  bleeding.  On  the  third  or  fourth 
day  I  begin  the  instillation  of  phenol  oil,  and  on  the  seventh 


HYPEEPLASTIC    SPHE:N'0IDITIS  185 

or  eighth  I  hegin  the  alkaline  saline  wash.  If  this  be  begun 
too  soon  it  conduces  to  bleeding,  probably  by  dissolving  the 
clots  in  the  vessels.  Synechias  in  the  posterior  district  are 
usually  negligible  clinically.  Should  it  be  desirable  to  dispose 
of  them,  I  wait  until  scarring  is  complete  and  divide  them  with 
a  sharp  knife.  Usually  the  scar  tension  will  pull  apart  the 
cut  surfaces  and  let  epithelium  cover  them.  If  the^^  be  in  a 
district  where  a  thin  celluloid  splint  can  be  retained,  this  may 
be  left  in  place  from  four  to  ten  weeks  assuring  epithelial  cov- 
ering   of  both  cut  surfaces. 

Surgery  of  the  Maxillary  Antrum 

Surgery  of  the  maxillary  antrum  may  be  radical  or  con- 
servative. The  former  which  ox)ens  the  antrum  in  some  way 
that  permits  the  curettement  of  its  lining  meml^rane  for  the 
relief  of  advanced  iDathological  changes  consequent  to  suppura- 
tion, granulation  and  necrosis  Avitli  polyps  is  never  required  for 
the  relief  of  the  uncomplicated  hyperplastic  changes  so  far  as 
I  know.  Should  the  outlet  to  the  antrum  become  closed  as  in 
the  cases  described  by  Lynch,*^  the  simple  opening  at  another 
place  for  ventilation  answers  the  puri)ose.  The  well-knowm 
Calclwell-Luc  and  the  Denker  radical  operations  therefore  need 
no  description  here.  The  procedure  which  has  all  the  advan- 
tages and  no  disadvantages  for  this  purpose  is  one  which  I  de- 
scribed in  1909.  Furthermore  it  answers  for  most  of  the  sup- 
purative cases. 

The  Author's  Antrum  Operation 

The  idea  of  entering  the  antrum  through  the  nasal  wall  and 
later  of  conserving  the  lower  turbinate  in  antrum  surgery  has 
occurred  to  various  surgeons.  So  far  as  I  know  the  first  com- 
pleted procedure  of  this  kind  A^as  at  my  hands  in  July,  1906. 
In  February,  1907,  Hirsch  conceived  and  performed  Avliat  is 
practically  the  same  operation.  He  reported  his  procedure  in 
the  Wiener  Medisinisclie  Wocliensclirift,  July  4,  1908.  My  re- 
port Avas  in  the  Larungoscope,  December,  1909.  He  confined 
his  operation  to  the  lower  meatus.  Mine  includes  the  middle 
meatus  also.  Aside  from  this,  there  are  some  other  small  vari- 
ations in  our  teclmicpies.     Both  have  as  cardinal  idea  the  con- 


186  HEADACHES    AKD    EYE    DISORDERS    OF    NASAL    ORIGIN 

servatioii  of  the  lower  turbinate  with  drainage  or  ventilation. 

The  operation  of  opening  into  the  antrum  of  Highmore 
through  the  lower  meatus  of  the  nose  was  first  described  by 
Schaeffer'^^  in  1885,  next  ])y  Mikulicz'=^  in  1886.  It  seems  to  be 
kno^^^l  usually  liy  the  name  of  the  latter,  Laek^^  describes  and 
suggests  leaving  a  cannula  in  position  that  tlie  patient  may 
wash  it  through. 

Rhinologists  now  seem  agreed  that  the  intranasal  operation 
is  the  choice  of  the  conservative  methods,  both  as  affording  per- 
manent drainage  and  doing  away  Avith  the  necessit}^  of  habitu- 
ally wearing  a  plug.  Should  these  conservative  means  prove 
insufficient,  and  a  radical  operation  be  required  later,  the  open- 
ing into  the  lower  meatus  will  not  have  been  in  vain.  Its  great 
drawback  is  the  removal  of  a  considerable  portion  of  the  lower 
turbinate,  which  is  followed  by  drying  of  the  corresponding 
nostril.  Furthermore,  the  stump  is  very  apt  later  to  become 
hypertrophied,  in  which  case  it  may  have  to  l)e  removed  with 
the  disadvantage  of  causing  increased  dryness  of  the  nostril. 
Hajek-'  emphasizes  this  tendency  to  hypertrophy,  and  offers 
the  explanation,  that  it  is  i^robably  a  result  of  congestion  fol- 
lomng  lesion  of  the  blood-vessels  incidental  to  the  resection. 

At  the  meeting  of  the  American  Medical  Association,  Sec- 
tion of  Laryngology,  held  in  Chicago,  June  1,  1908,  while  dis- 
cussing Canfield's  "Submucous  Resection  of  the  Lateral  AVall 
of  the  Nose,"^  I  described  my  o^Am  modification  of  the  "Miku- 
licz" operation.  The  operation,  as  I  then  described  it,  and  as 
I  have  performed  it  for  the  past  ten  years,  is  simple  in  execu- 
tion ;  and,  when  j^roperly  done,  assures  a  permanent,  free  open- 
ing for  drainage.  It  avoids,  moreover,  the  subsequent  drying, 
which  is  the  only  drawback  to  the  lower  meatus  operation.  It 
involves  only  an  insignificant  lengthening  of  the  time  required 
in  operating. 

The  procedure  consists  (1)  in  cutting  the  lower  turbinate 
from  the  lateral  wall,  as  far  back  as  its  posterior  fourth,  by 
means  of  scissors.  The  detached  part  is  then  pushed  well  up- 
wards, while  the  operator  removes  the  lateral  wall  of  the  lower 
meatus  Fig.  106.  Fig.  107  shows  a  separable  forceps,  helpful 
in  making  a  quick  effective  entrance  to  the  antrum  from  the 
nose.    When  the  wall  of  the  lower  meatus  passes  outward  as 


HYPERPLASTIC    SPHENOIDITIS 


187 


well  as  backward  it  is  often  difficult  to  secure  a  satisfactory 
beginning  for  the  opening  because  an  ordinary  biting  forceps 
fails  to  effect  the  first  bite — it  slips.  In  order  to  overcome  this 
difficulty  I  have  made  one  blade  of  these  forcejDS  lance-like.  It 
is  separated  from  its  cup-shaped  fellow.  It  is  passed  through 
the  anterior  limit  of  the  nasal-antral  Avail  just  as  a  straight 


Fig.    106. — I.  Detached    lower    turbinate.      2.  Opening    cut    into    antrum. 

needle  used  in  the  exploratory  puncture  of  this  cell.  While  it 
is  in  this  position  its  cup-shaped  fellow  is  introduced  and  locked 
just  as  the  blades  of  the  obstetrical  forceps  are  introduced 
separately  and  locked  before  they  are  put  to  service.  A  strong 
bite  is  then  put  upon  the  instrument  and  by  a  to-and-fro  lateral 
rocking  movement  a  considerable  part  of  the  wall  is  loosened  and 


188  HEADACHES   AND    EYE    DISOEDERS    OF    NASAL    ORIGIN" 

removed.  The  blades  should  he  tempered  and  the  cup  sharp 
as  great  power  is  needed  in  these  forceps  when  the  wall  is  thick. 
If  the  cup  is  not  sharp  it  will  slip.  Figs.  108  and  109  are  self- 
explanatory.  After  the  first  entry  has  been  satisfactorily  made 
it  is  usually  not  difficult  to  reenter  it  and  enlarge  it,  by  these 
forceps  or  any  other  the  surgeon  may  prefer.  The  detached  part 
of  the  lower  turbinate  is  next  pushed  doAvn  into  the  lower 
meatus,  while  he  removes  as  much  of  the  Vv^all  of  the  middle 
meatus  as  he  wislies  (Fig.  110).    In  this  manner  it  is  possible 


Fig.    107.- — The   author's   intra-nasal   antrum   forceps.* 

to  remove  the  entire  inner  wall  of  the  antrum  as  far  forward 
as  the  nasal  process  of  the  maxilla.  There  will  still  remain 
the  ridge  on  the  nasal  process,  for  the  reattachment  of  the 
lower  turbinate,  which  is  now  replaced  in  its  original  posi- 
tion, carefully  apposing  the  cut  surfaces  at  the  anterior  end 
(Fig.  111).  Often  the  parts  may  be  held  in  position  b}^  means 
of  a  little  cotton  or  gauze.  If  this  is  found  to  be  insufficient, 
one  or  tAvo  stitches  suffice  to  hold  everything  perfectly  in  place. 
i  have  never  seen  the  bone  fail  to  unite,  or  undergo  degenera- 
tion.    No  subsequent  hypertrophy  has  been  observed.     Some 


*To  be  had   of  V.   Mueller   &  Co.,  Chicago,   III. 


HYPERPLASTIC    SPHENOIDITIS 


189 


Fig.   108 


190  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIjST 

of  my  cases  are  of  ten  years'  standing.  The  replaced  tnrbinate 
in  no  wise  interferes  with  the  drainage,  or  with  the  final  good 
results.  It  does  away  absolutely  with  any  subsequent  drying. 
This  is  an  advantage  in  cases  both  of  medium  and  wide  nos- 
trils, Avhere  some  drying  is  sure  to  follow  any  removal  of  the 
turbinate.  It  is  especially  advantageous  also  in  cases  in  which 
the  middle  turhinaie  must  he  or  has  been  removed  to  drain  a 


Fig.    110. 

frontal  or  ethmoidal  empyema.  In  these  cases  it  conserves 
the  heat  and  moisture  functions  of  the  nose,  Avliich  would  be 
lost  were  both  turbinates  removed.  In  atrophic  rhinitis  it  is 
especially  indicated. 

In  noses  whose  calibre  is  a  little  too  wide  or  a  little  too 
narrow  the  angle  of  inclination  of  the  turbinate  may  be  altered 


HYPERPLASTIC    SPHEXOIDITIS 


191 


in  reattaching  it,  making  it  less  acute  for  tlie  former  and  more 
acute  for  the  latter.  This  is  readily  done  by  tilting  the  bone 
upwards  by  a  pack  of  gauze  or  cotton  put  underneath  its  body 
after  it  has  been  se^^^l  in  place,  or  by  pressing  the  body  slightly 
outwards  by  a  pack  between  it  and  the  septum.  These  packs 
must  be  continued  throughout  the  healing,  the  bone  afterwards 
remaining  in  its  new  position. 


Fig.    111. — Showing    /    lower    turbinate    replaced    to    original    position. 


Opening    into    antrum. 


It  is  my  habit  to  remove  the  entire  inner  wall  of  the 
antrum — opening  it  into  the  middle  as  ^vell  as  the  lower 
meatus — replacing  the  lower  turbinate  as  above  described.  I 
believe  it  is  best  to  remove  the  wall  of  the  middle  as  well  as 
of  the  lower  meatus,  for  the  reason  that  an  opening  limited  to 
the  lower  meatus  will  often  close  up. 


CASE  HISTORIES 

Case  histories  are  snlmiitted  with  some  effort  to  conform 
to  the  patliological  lesion.  It  has  however  seemed  to  me  more 
interesting  to  keep  in  mind  the  predominating  featnre.  This 
will  explain  why  the  categories  overlap  in  many  places,  also 
the  seeming  neglect  to  separate  nasal  ganglion  cases  from  the 
sphenoidal  cases.  This  may  appear  more  logical  when  it  is 
recalled  that  the  ''lower-half  headache"  is  the  most  striking 
manifestation  of  both  lesions  as  has  been  made  clear  in  the 
body  of  the  text.  I  have  deliberately  recorded  many  features 
which  at  first  thought  may  appear  so  rare  or  infrequent  as  to 
deny  the  justice  of  their  report.  AVlien  they  have  been  the 
only  cases  I  have  stated  this  fact.  In  recording  unusual  cases 
I  am  justified  by  the  precedent  of  the  most  famous  neurologists 
of  recent  times;  to  wit,  Dr.  S.  Weir  Mitcliell,^^  Sir  Wm.  R. 
Gowers,"  and  Dr.  C.  W.  Suckling,^"  and  others  who  have  re- 
corded unusual  cases,  no  explanation  for  which  could  l^e  given 
at  the  time.  They  justified  the  record  of  facts  by  the  hope 
that  the  future  might  discover  their  causes. 

Vacuum  Frontal  Headaches 

Miss  A.  B.,  28  years  old,  referred  to  me  by  Dr.  A.  E. 
Ewing,  Oct.  20,  1898,  for  frontal  headache  with  asthenopia  ex- 
amination showed  a  large  tuberculum  septi  crowding  the  mid- 
dle turbinate  of  each  side  tight  to  the  lateral  wall.  Both  tur- 
binates were  removed  in  November,  1898.  Examination  by  Dr. 
"Wright  showed  normal  turl)inates.  I  append  Dr.  Ewing 's  re- 
port. This  patient  shoAvs  age  b}^  change  in  the  skin  with  almost 
no  change  of  feature.  She  has  never  had  any  recurrence  (May 
1918). 

"Patient  received  Oct.  23,  1897.  In  this  case  I  (Ewing) 
was  for  a  long  time  deceived,  the  tenderness  not  being  suffi- 
ciently marked  to  be  regarded  by  me  as  decisive.  When  the 
patient  first  came  to  me  there  was  marginal  blepharitis  com- 


CASE    HISTORIES  193 

plicated  with  conjunctivitis,  also  liypernietropia  witli  astigma- 
tism. The  eyes  had  been  inflamed  from  time  to  time  for  several 
years,  and  at  times  there  was  a  good  deal  of  headache.  AYith 
correction  of  the  refraction  and  care  of  the  lids,  the  inflannnation 
in  the  main  disap})eared,  and  the  headaches  were  greatly  les- 
sened, but  there  was  always  inability  to  nse  the  eyes  by  arti- 
ficial light.  The  relapses  of  conjunctivitis  were  also  frequent. 
Afterwards  the  headaches  became  more  frecpient,  and  were 
made  worse  ])y  any  use  of  the  eyes  in  near  work.  As  the  sub- 
ject was  a  teacher,  some  use  of  the  eyes  was  imperative.  There 
Avas  some  weakness  of  the  interni  which  I  corrected  with  prisms, 
to  be  worn  in  near  work  in  addition  to  the  spectacles  which  cor- 
rected the  refractive  error.  For  a  time  these  served  fairly  well, 
with  periods  every  two  or  three  weeks  during  which  the  eyes 
could  not  be  used  even  with  this  aid.  The  headaches  gradually 
became  more  frec[uent,  and  Avere  finally  almost  constant. 

"Eventually,  Avhen  I  had  almost  concluded  that  my  patient 
was  a  confirmed  neurotic,  I  detected  during  a  slight  exacerbation 
of  the  conjunctivitis  a  positive  tenderness  in  one  orbit.  A  rhi- 
nological  examination  by  Dr.  Sluder  revealed  closure  of  the 
frontal  sinu^.  Under  appropriate  treatment  for  this  condition 
the  headaches  and  the  conjunctivitis  have  entirely  disappeared, 
the  prisms  have  been  discarded,  and  the  eyes  are  used  freely 
da}'  and  night." 

L.  M.,  aged  15,  consulted  me  September  22,  1902.  For  5 
years  he  had  had  a  great  deal  of  trouble  from  headache  and  his 
eyes  (asthenopia),  which  interfered  with  his  education.  He 
had  been  sent  to  Texas  to  have  the  life  of  the  open  air  upon  a 
ranch,  thinking  that  would  stop  the  headache  and  relieve '  his 
eyes  so  that  they  might  come  into  service. 

All  effort  to  relieve  him  failed,  and  he  was  brought  to  me 
for  examination. 

It  was  found  that  the  middle  meatus  of  each  side  was 
closed  by  the  middle  turbinates  being  pushed  into  the  lateral 
wall  by  the  tubercle  of  the  septum.  E wing's  sign  was  very 
clearly  marked.  The  case  seemed  perfectly  clear  as  a  closure 
of  the  frontal  sinus  without  secretion. 

January  19,  1903,  tlie  right  middle  turl)inate  was  removed. 
Deceml)er  29,  1902,   the  left  turljinate  removed.     The  wound 


194  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

healed  iineveiit fully,  and  the  headache  stopped,  and  his  eyes 
went  into  service,  which  permitted  the  complete  education  of 
the  young  man,  according  to  the  standards  of  the  family.  He 
went  through  college  and  became  a  celebrated  athlete.  For 
some  time  he  has  been  in  business  in  St.  Louis,  and  from  time 
to  time  I  see  him.  He  remains  free  of  headache.  His  eyes  are  as 
serviceable  as  anyone's.  He  shows  his  age  more  by  the  altera- 
tion in  the  skin  than  in  change  of  feature.  The  bony  configura- 
tion of  his  skull  changes  very  little. 

The  turbinates  were  normal  (Dr.  Wright). 

This  case  is  a  sharp  contrast  to  M.  E.'s,  where  the  uncinate 
process  and  the  bulla  became  approximated  after  a  short  time, 
necessitating  the  removal  of  the  floor  of  the  frontal  sinus  by  a 
burr. 

Vacuum  Frontal  Headache  with  Active  Hyperplastic 
Bone  Process 

M.  E.,  40  years  old,  consulted  me  Dec.  20,  1903,  because  of 
symptoms  almost  the  same  as  L.  M. 

Removal  of  the  middle  turbinate  gave  relief  for  nine  years 
when  the  inlet  to  the  frontal  was  obliterated  b}^  enlargement 
of  the  bulla  to  approximate  the  uncinate  process  as  high  up  as 
the  cribriform  plate.  On  Oct.  10,  1912,  I  removed  the  uncinate 
and  floor  of  tlie  frontal  making  a  large  opening  which  so  far 
has  remained  open. 

Clinically,  the  case  is  an  active  hyperplastic  anterior  eth- 
moiditis.     She  shows  age  markedly  by  change  of  bony  feature. 

It  is  not  possible  at  present  to  connect  the  external  face 
which  changes  in  features  as  age  increases,  with  the  activity  of 
the  hyperplastic  process  Avithin  the  nose.  I  have  however  ob- 
served it  often. 

Vacuum  Frontal  Headache  with  Sphenoidal 
Involvement  Later 

Mrs.  J.  B.  C,  33  years  old,  referred  by  Dr.  M.  H.  Post, 
October  26,  1910,  for  frontal  sinus  vacuum  headache  of  15 
years'  standing,  with  asthenopia,  high  grade.  March  16,  1911, 
I  removed  bj^  high   (cribriform)  cut,  the  L.  middle  turbinate. 


CASE    HISTORIES  195 

It  showed  (Dr.  Wright's  examination)  a  hyperplastic  (bone  and 
soft  parts)  process.  The  R.  side  was  less  tronblesome  and  not 
operated.  She  got  well  and  remained  so  nntil  sent  by  Dr.  J. 
A.  Fhiry  again  to  me  Jnly  8,  1915,  with  a  well-marked  hj^per- 
plastic  sphenoiditis,  non-snppnrative,  more  marked  L,  accom- 
panied by  moderate  maxillary  and  Vidian  nenralgia  with  a  hazi- 
ness of  the  retina  and  a  blurring  of  the  disc  of  both  eyes  with 
vision  L.  6/9,  R.  6/6  metric.  She  Avas  given  a  l^/o  per  cent 
alkaline  saline  solution  to  pour  into  the  nose  three  times  a  day 
and  a  phenol  spray.  Improvement  began  in  two  Aveeks.  Sep- 
tember 13,  1915,  she  reported  herself  to  be  ' '  well. ' '  Dr.  Flury 
reported  the  fundi  V.  R.  and  L.  normal, 

I  liaA'e  three  similar  cases  beginning  15, 17,  and  20  years  ago, 
respectively,  as  frontal  vacuum  headaches. 

The  middle  turbinate  bones  shoAved  hyperplasia  of  bone 
and  soft  parts  (Dr.  Wright).  They  remained  Avell  after  opera- 
tion until  the  past  3  years,  since  Avhich  time  they  liave  developed 
a  hyperplastic  post-ethmo-sphenoiditis,  one  Avith  polyps  above 
the  middle  turbinate  line.  All  haA^e  loAver-half  headache  in  great 
degree  and  A^ery  often ;  but  no  fundus  changes. 

In  one  case  a  major  epilepsy  ceased  after  a  post-ethmoidal- 
sphenoidal  operation.    He  has  been  Avell  noAv  17  years. 

The  First  Nasal  Ganglion  Case 

Mr.  S.,  45  years  old,  consulted  me  Xovember  23,  1903.  For 
ten  years  he  had  suffered  from  headache  Avhich  incapacitated 
him  for  business  tAvo  or  three  days  of  almost  every  Aveek.  Noth- 
ing in  his  general  health  or  life  Avas  at  fault.  He  defined  the 
distribution  of  pain  as  l^eginning  at  the  root  of  the  nose  on  the 
right  side,  taking  in  the  upper  jaAV,  and  extending  backAvard 
to  become  emphasized  at  the  tip  of  the  mastoid  for  a  distance 
of  5  cm.  posterior  to  it.  The  attacks  Avere  not  always  of  equal 
severity.  During  a  milder  attack  he  could  continue  his  business. 
In  seA^ere  attacks  the  pain  extended  to  the  neck,  shoulder,  and 
shoulder  blade  of  the  same  side,  and  Avas  so  intense  as  to  com- 
pel him  to  go  to  bed.  They  Avere  accompanied  by  A^omiting, 
These  seA^erer  attacks  lasted  from  tAvelve  to  tAventy-four  hours. 
Examination  of  the  nose  shoAved  a  duskA^  red  SAvollen  area  in- 


196  HEADACHES    AND    EYE    DISORDERS    OE    NASAL    ORIGIN 

the  right  olfactory  fissure  about  1.5  eui.  in  diameter,  roughly 
•circular,  lieginuiug  on  the  anterior  wall  of  the  sphenoidal  cells 
and  extending  forward  (the  sphenopalatine  foramen  district). 

Applications  of  a  2  per  cent  silver  nitrate  solution  were 
made  to  the  atfected  area  two  or  three  days  a  week  for  al)out 
three  months.  It  finality  became  normal  in  appearance.  With 
the  improving  appearance  of  this  area  went  hand  in  hand  a 
lessening  of  the  frequency  and  severity  of  the  attacks  of  pain, 
until  they  ceased.  Since  that  time  he  has  enjoyed  freedom  from 
painful  attacks  except  at  the  time  of  coryza.  Coryzas  of  medium 
severity  are  accompanied  by  a  moderately  severe  attack  of 
pain,  as  described  before.  He  had  one,  more  severe  coryza  which 
was  accompanied  by  great  pain. 

After  I  had  learned  to  associate  these  neuralgic  manifes- 
tations with  the  nasal  ganglion,  and  to  apply  the  anaesthetic 
in  its  immediate  neighborhood  (October,  1907),  I  was  always 
able  to  stop  the  pain  during  coryzas.  With  this  x>atient  anaes- 
thetizing the  ganglion  aborts  tlie  attack.  At  the  present  time 
(1918)  he  is  well.  During  the  past  three  years  he  has  had  one 
slight  attack  from  a  coryza. 

Miss  S.,  27  years  old,  consulted  me  June  13, 1906.  For  many 
years  "off  and  on,"  she  had  suffered  from  pain  in  the  liead, 
which  she  described  as  paroxysmal,  beginning  at  the  root  of 
the  nose,  involving  the  upper  jaw  and  teeth  (occasionally  also 
the  lower  jaw  and  teeth),  extending  backward  to  the  tip  of  the 
mastoid,  and  liecoming  intensest  ahout  5  cm.  posterior  to  the 
point. 

These  paroxysms  recurred  sometimes  two  or  three  times  a 
week ;  and  when  at  her  best,  at  intervals  of  two  or  three  months. 
Examination  of  the  nose  was  negative  in  every  particular.  She 
made  the  ol)servation,  however,  dui'ing  an  attack,  that  the  co- 
caine which  had  been  sprayed  into  her  nose,  a  four  per  cent 
solution,  had  relieved  her  of  the  pain. 

In  the  absence  of  a  definite  diagnosis,  but  continuing  the 
spraying  of  the  nose  with  cocaine,  it  was  found  that  each  ap- 
plication appreciably  mitigated  the  pain.  Under  this  treatment, 
in  apparently  much  improved  condition,  she  parsed  from  ob- 
servation. About  three  months  later  she  returned  for  treat- 
ment of  a  severe  coryza,  Avhich  in  ten  days  localized  itself  in 


CASE    HISTORIES  197 

a  suppnratiiif;'  inflaiiiination  of  the  post-ethmoidal  and  sphe- 
noidal sinuses  of  l)oth  sides.  Ahnost  simultaneously  the  old 
pain  reappeared,  on  the  left  side,  involving  tlie  root  of  the  nose, 
the  cheek,  the  mastoid  tip,  and  a  little  behind  it,  the  neck,  shoul- 
der-blade, shoulder,  and  arm — all  in  great  severity. 

Remembering  the  position  of  the  nasal  ganglion,  in  close 
proximity  to  these  sinuses,  and  the  widespread  distribution  of 
its  branches  and  connections,  I  felt  that  this  distril)ution  of  pain 
was  possibly  due  to  the  inflammation  or  its  products  extend- 
ing to  or  acting  upon  the  ganglion ;  and,  if  this  was  true,  that 
cocaine  applied  (soaked)  over  the  sphenopalatine  foramen  might 
probably  prove  effective  in  at  least  mitigating  the  pain. 

The  experiment  A\'as  tried,  and  succeeded  even  beyond  ex- 
pectation. Since  then  I  have  applied  the  cocaine  for  her  at  the 
same  site  in  severe  recurrent  attacks,  probal^ly  twenty  times; 
always  relieving  tlie  pain  and  usually  aborting  the  attack. 

I  liave  also  done  some  experimenting  in  these  cases,  but 
particularly  in  this  case.  During  an  attack  an  application  of 
a  single  drop  of  dilute  solution  4  per  cent  cocaine,  through  the 
region  overlying  the  ganglion,  was  followed,  by  onl}^  the  faintest 
relief.  This  dilute  solution  was  then  replaced  by  a  drop  of  a 
10  per  cent  cocaine  solution,  with  more  relief.  A  drop  of  20  per 
cent  solution  was  then  applied,  with  further  lessening  of  the 
pain.  A  drop  of  a  saturated  solution  (about  67  per  cent)  Avas 
then  applied,  when  the  relief  would  usually  become  complete. 
Applications  to  other  areas  gave  negative  results.  In  very 
severe  attacks  the  pain  would  stop  except  at  the  point  5  cm. 
posterior  to  the  tip  of  the  mastoid,  where,  altliougli  greatly 
mitigated,  it  never  quite  disappeared ;  a  very  slight  pain  always 
remained  here.  The  applications  were  allowed  to  remain  twenty 
minutes  in  position. 

This  patient  suffered  greatly  from  repeated  attacks  until 
December  1,  1908,  when  I  began  injections  of  alcohol:  making 
the  attempt  to  put  the  alcohol  in  direct  contact  with  the  gan- 
glion. A  straight  needle  directed  upward  and  outward  under 
the  posterior  fourth  of  the  middle  turl)inate  will  roach  the  sphe- 
nopalatine fossa  just  where  the  ganglion  lies.  Tlie  needle  must, 
however,  be  passed  ol)li(|uely  through  the  lateral  wall  of  the  nose, 
which  in  this  case  Avas  so  hard  as  to  make  the  procedure  im- 


198  HEADACHES    AXD    EYE    DISORDERS    OF    :^ASAL    ORIGIN 

possible.  I  thereupon  drilled  through  the  hone,  thus  removing 
the  ohstaele  to  the  passage  of  the  needle  into  the  pterygoxjalatine 
fossa  and  opening  an  easy  route  for  subsequent  injections.  The 
injection  of  the  alcohol  aggravated  the  characteristic  pain  al- 
ready described,  but  tlie  exacerbation  was  transitory  and  was 
followed  by  relief. 

After  a  course  of  ten  injections  the  relief  seemed  complete ; 
but,  after  somewliat  more  than  three  weeks  of  freedom  from 
pain,  the  patient  contracted  another  severe  coryza,  with  sup- 
purative inflammation  of  the  post-ethmoidal  and  sphenoidal 
cells  of  both  sides,  rekindling  the  old  pain  now  for  the  first  time 
also  on  the  right  side,  although  with  less  severity  than  on  the 
left  side.  One  application  of  saturated  cocaine  solution  on  the 
right  side,  posterior  to  and  slightly  above  the  posterior  tip  of 
the  middle  turbinate  stopped  the  pain  and  it  did  not  recur.  On 
the  left  side  relief  was  more  tardy. 

Miss  S.  had  recently  had  another  "explosion,"  which  was 
relieved  by  one  drop  of  saturated  cocaine  solution  to  the  gan- 
glion \vdth  the  exception  of  a  rather  severe  pain,  which  persisted 
in  the  shoulder  blade  of  that  side.  On  the  next  day  the  cocaine 
application  was  repeated,  with  complete  relief  of  the  pain. 

At  i)resent  (1918)  she  is  free  of  pain  except  at  times  of  a 
coryza.  Then  it  develops  in  her  teeth  and  between  her  shoul- 
der blades  where  it  feels  like  a  '"ball  of  fire." 

Complete  Case  of  Nasal  Ganglion  Neuralgia 

Mrs.  N.,  sister  to  Mr.  S.,  whom  I  had  seen  many  times  in 
acute  coryzas,  came  February,  1909,  with  Avliat  appeared  to  be 
a  coryza  of  ordinary  severity ;  she  complained,  however,  of  pain 
as  in  a  typical  case  of  nasal  ganglion  neuralgia.  One  applica- 
tion of  cocaine  afforded  comx)lete  relief,  and  there  was  no 
recurrence  of  pain.  The  coryza  was  otherwise  commonplace  and 
uneventful. 

Since  that  time  I  have  seen  Mrs.  N.  many  times  for  vari- 
ous troubles.  One,  an  enlargement  of  the  thyroid,  which  seemed 
to  be  secondary  to  a  lingual  tonsillitis.  The  lingual  tonsil  has 
been  treated,  resulting  in  a  lessening  of  the  volume  of  the 
thyroid  and  the  cessation  of  the  nervousness  and  weakness  of  the 
hyperthyroidism  which  M^as  at  the  time  cpiite  pronounced.    She 


CASE    HISTORIES  199 

had  no  more  g:aiiglion  neuralgia  nntil  the  winter  of  1916  and 
1917.  Then  in  the  wake  of  what  appeared  to  be  an  ordinary 
coiyza  she  again  complained  of  pain  described  briefly  as  a 
^'lower-half  headache,"  severe,  accompanied  by  violent  sneez- 
ing and  a  sense  of  very  strong  mustard  in  the  nose,  lacrimation 
and  marked  asthenopia.  The  entire  picture  was  marked;  l)ut 
knowing  that  she  had  passed  through  such  an  attack  of  a  much 
milder  nature  on  an  occasion  before,  I  felt  that  she  would  prob- 
ably survive  this  attack  without  injection  of  the  ganglion,  which 
I  therefore  postponed. 

The  case  ran  a  series  of  ups  and  downs,  more  or  less,  last- 
ing throughout  the  autumn  and  winter.  It  stopped  in  the  mid- 
dle of  spring.  Since  that  time  she  has  been  perfectly  well,  free 
of  all  disturbance  referable  to  the  nasal  ganglion. 

Locally,  her  nose  showed  a  perfectly  clear  post-ethmoidal 
sphenoiditis  of  what  I  suppose  might  be  termed  the  catarrhal 
type ;  that  is,  there  was  no  suppuration,  no  swelling  of  the  mem- 
brane; the  appearance  was  simply  one  of  redness  with  serous  in- 
cretion;  throughout  the  attack  cocaine  to  the  ganglion  stopped 
the  pain  and  relieved  all  symptoms  for  a  number  of  days  at  a 
time. 

In  this  case  of  course  the  position  of  the  nasal  ganglion 
remained  imchanged  throughout  these  years.  From  the  time 
of  the  first  pain  manifestation  until  this  now  reported,  she  has 
passed  through  many  coryzas  of  ordinary  severity,  none  of 
which,  however,  excited  pain.  Such  a  case  seems  to  me  to  argue 
that  the  organism  that  produces  the  coryza  must  vary  from  time 
to  time,  and  that  there  is  a  special  organism  or,  possibly,  more 
than  one,  that  has  a  predilection  for  the  nerve  tissues;  and  that 
there  are  others  that  pass  through  their  course  with  just  as 
much  appearance  of  inflammation  as  the  other  attacks,  but  which 
make  no  symptoms  vritli  the  nerve  tissues. 

Simple  Ganglion  Neuralgia 

Mr.  B.,  3.J  years  old,  came  to  me  Septeml)er  24,  1907,  with 
a  high  grade  deflection  of  the  septum,  Avhich  I  resected.  The 
operation  was  in  every  way  uneventful  and  satisfactory.  May 
14,  1908,  he  returned  with  an  acute  suppurative  inflammation  of 
the  post-ethmoidal  and  sphenoidal  cells  of  both  sides,  accom- 


200  HEADACHES    AND    EYE    DISORDERS    OF    XASAL    ORIGi:Nr 

panied  by  a  lieadaelie  referred  to  the  parietal  eminence  and 
occiput  of  both  sides,  which  histed  seven  days.  Three  days 
later  pain  developed,  which  he  described  as  beginning  in  the 
root  of  the  nose,  taking  in  the  maxilla,  extending  back^vard  into 
the  occiput,  and  downward  into  the  neck  and  shonlder  ])lade. 
It  improved  nnder  applications  of  0.4  joer  cent  formaldehyde 
solution  over  the  sphenopalatine  foramen.  Patient  was  com- 
pletely well  June  23,  1908,  and  remained  so  with  the  exception 
of  some  occasional  disturbances  from  coryzas. 

Simple  Sphenoiditis-Suppurative 

Miss  DeH.,  20  years  old,  referred  by  father.  Dr.  Deli.  For 
three  years  a  profuse  suppuration  of  sphenoid  sinuses.  Never 
any  headache  or  other  symptoms.  Hajek  post-ethmoidal-sphe- 
noidal  operation.  Dr.  Wright  reported  "Membrane  not  mark- 
edly altered.    No  involvemejit  of  periosteum  or  lione." 

Simple  Inflammation 

Mrs.  P.,  55  years  old.  Diagnosis,  sphenoidal  empyema. 
Pain  in  occiput,  left,  G  months.  Relieved  by  operation.  Re- 
ferred by  Dr.  A.  E.  Ewing.  Dr.  Wright's  report:  Sphenoidal 
tissue — bone  shows  some  hyperplasia  and  there  are  marked  in- 
flammatory products  in  the  soft  parts.  Middle  turbinate  shows 
marked  inflammation  of  nmcous  membrane  in  its  deeper  layers 
and  considerable  hyperplasia  of  the  periosteum  along  the  bone 
areas;  the  bone  itself  is  perhaps  slightly  thickened  and  the  area 
of  its  distribution  is  considerable.  In  some  places  the  bone 
seems  to  be  very  much  thickened  and  the  veins  which  it  con- 
tains are  gorged  with  blood. 


&' 


Hyperplastic  Sphenoiditis 

Miss  M.  M.,  37  years  old,  February  26,  1908,  consulted  me 
for  general  headache  Avith  great  morning  sneezing.  There  was 
swelling  of  the  cavernous  tissues  in  the  nose  Avith  profuse  gen- 
eral watery  secretion ;  but  no  pus  or  visi])le  evidence  of  sphe- 
noidal inflammation.  In  the  effort  to  control  this  syndrome 
the  anterior  nasal  nerves  were  injected  Avitli  alcohol  (Stein) 
and  trichloracetic  acid  applied  to  the  tubercle  of  the  septum 


CASE    HISTORIES  201 

(Francis)  and  middle  turlnnate,  finally  the  galvanocantery  to 
lower  turbinates  and  tubercle,  November  6,  1908;  December  26, 
1908.  The  nose  was  opened  for  air,  but  the  sneezing  continued. 
All  efforts  failed.  She  had  to  abandon  a  Imsy  and  very  useful 
life  for  an  indefinite  period  of  rest.  Dr.  D.  B.  Delavan,  who 
saw  her  in  consultation,  advised  rest  in  the  mountains.  After 
six  months  in  the  mountains  of  the  South  she  returned  to  St. 
Louis,  well,  and  remained  so  for  one  year.  At  this  time,  March 
17,  1910,  she  returned  for  treatment  because  of  a  "bad  cold  and 
headache,"  as  she  expressed  it.  She  showed  a  bilateral  post- 
ethmoidal-sphenoidal  suppuration,  for  which  I  eventually  op 
erated,  both  sides  (April  21,  October  27,  1910).  On  Januaiy  10, 
1911,  she  returned  to  me  for  an  acute  coryza  with  general  head- 
ache and  almost  insufferable  sneezing  (sneezing  to  exhaustion) 
without  evidences  of  post-ethmoidal-sphenoidal  suppuration, 
for  which  she  was  again  compelled  to  retire  to  the  mountains. 
June  12,  1911,  she  again  reported  to  me  well.  October  12,  1911, 
she  consulted  me  because  of  intractable  sneezing  and  general 
headache  with  intense  burning,  stinging  sensation  in  the  nose 
ensuing  upon  a  coryza.  This  time  I  began  the  intra-sphenoidal 
applications  of  1  per  cent  cocaine  in  oil,  with  1  per  cent  phenol 
in  oil,  which  controlled  the  sneezing  and  headaclie  fairly  well. 
A  little  later  I  began  applications  of  2  to  5  per  cent  sodium 
salicylate  water  solutions,  which  proved  much  more  satisfac- 
tory— the  sneezing  and  headache  stopped  in  about  six  days. 
February  17,  1912,  a  coryza  again  made  general  headache  and 
sneezing.  This  time,  knowing  that  salicylate  of  methyl  was  a 
more  potent  remedy  than  the  soda  salt,  and  that  it  was  usually 
tolerated,  I  filled  the  sphenoid  with  a  5  per  cent  solution  syn- 
thetic methyl-salicylate  solution  in  oil.  To  my  surprise  and 
disappointment  it  aggravated  the  entire  syndrome  in  great  se- 
verity, and  in  addition  produced  asthma  lasting  five  days.  A 
little  later,  after  applications  of  the  sodium  salt,  she  became 
comfortable;  and  this  in  a  much  shorter  time  than  in  the  pre- 
ceding attacks.  Locally  this  ease  behaves  like  a  hyperplastic 
ethmoiditis.  In  the  inflammatory  stage  the  membrane  becomes 
edematous  with  polyp  formations,  which  subside  Avlien  the  at- 
tack is  over. 

Up  to  the  present  time  she  continues  to  be  disturbed  greatly 


202  HEADACHES    AXD    EYE    DLSORDERS    OF    NASAL    ORIGIX 

by  a  coryza,  a  slight  eoryza  producing  violent  burning,  as  mus- 
tard, inside  of  the  nose,  with  great  pain  which  wakes  her  out 
of  her  sleep  at  night,  "When  the  case  is  severe,  asthma  devel- 
ops, with  the  headache  which  accompanies  this  syndrome  with 
greater  or  less  severity.  The  case,  however,  yields  through  in- 
stillation of  one-third  per  cent  carbolic  acid  within  the  sphenoid 
sinus  better  than  to  anything  that  has  been  tried.  Two  per 
cent  mentliol  instilled  into  sinus  produced  violent  headache  and 
severe  asthma.  Most  of  the  time  she  is  comfortable.  She  is  a 
very  busy  hard-working  woman.  In  her,  a  coryza  is  ah\'ays  ac- 
companied by  polyps  within  the  sphenoid,  which  subside  as 
soon  as  the  severity  of  the  coryza  is  passed.  Dr.  "Wright's  ex- 
amination of  sphenoid  tissue  shows  marked  ostitis  and  peri- 
ostitis. 

Hyperplastic  Process  Advancing  Under  Observation 

S.  E.,  aged  23  years,  consulted  me  in  1S98  Ijecause  of  in- 
tractable low  grade  frontal  headache  made  worse  by  use  of  the 
eyes.  She  was  referred  to  me  by  Dr.  John  Green.  Effort  to  re- 
lieve the  eye  condition  was  unsuccessful.  Nasal  examination 
showed  the  middle  turbinate  crowded  to  the  lateral  wall  by  the 
tubercle  of  the  septum.  She  had  been  passed  as  a  neurotic  by 
the  neurologists.  Verj^  little  hope  was  held  out  for  any  benefit 
excejDt  possibly  by  the  lapse  of  time.  Removal  of  the  middle 
turbinate  relieved  the  frontal  headache,  stopped  the  general 
nervous  condition  and  restored  her  eyes  to  full  usage.  She  re- 
mained free  of  pain  for  six  years,  at  which  time  she  suffered  a 
frontal  sinus  infection  with  pus.  She  had  a  low  grade  headache 
with  this,  which  lasted  two  weeks  and  sul)sided  practically  with- 
out treatment.  Twice  she  has  had  suj^purative  infections  of  the 
frontal  and  the  anterior  ethmoid.  The  case  has  been  of  great 
interest  in  observation  showing  the  gradual  increase  of  volume 
of  the  bulla  of  the  ethmoid,  a  thickening  of  the  uncinate  proc- 
ess of  the  ethmoid  and  a  swelling  of  the  membrane.  Xow  she 
has  a  considerably  swollen  membrane,  the  inlet  to  the  frontal 
sinus  is  considerably  narrowed  and  she  suffers  more  or  less  dis- 
comfort with  each  coryza.  Of  greater  interest,  however,  is  the 
observation  that  three  years  ago  began  the  appearance  of  swell- 
ing with  i^olyps  above  the  line  of  origin  for  the  middle  turbinate. 


CASE    HISTORIES  203 

Since  that  time,  of  greatest  interest,  is  the  posterior  pain  wliich 
has  developed  since  the  inflammatory  trouble  has  been  above  the 
middle  turbinate  and  backward.  At  present  she  has  a  very  well- 
marked  hyperplastic  post-ethmoidal  sphenoiditis  which  with 
each  coryza  makes  jiolyps  in  considerable  number  and  volume. 
In  the  interval  between  the  coryza  the  polyjis  disappear,  all  ex- 
cept one  which  is  in  the  anterior  ethmoid  and  which  becomes 
very  much  smaller.  Much  of  the  time  she  is  free  of  all  pain. 
Any  little  inflammatory  trouble  in  her  nose  which  mio-ht  other- 
wise not  be  recognized  is  registered  as  headache  either  frontal  or 
occipital.  This  case  is  to  me  very  interesting  sho"v\T.ng  the  grad- 
ual extension  of  the  process  from  a  hyperplastic  anterior  etli- 
moiditis  of  low  grade  to  the  posterior  district  where  the  typical 
lower-half  headache  has  been  repeatedly  produced.  In  this  case 
a  cut  which  removed  the  middle  turbinate  was  in\t  up  or  nearly 
to  the  cril)riform  plate,  the  cut  which  I  have  repeatedly  spoken  of 
as  a  cribriform  turbinectomy.  It  still  shows  an  inlet  to  the  fron- 
tal sinus  of  l^  inch.  In  the  beginning  the  inlet  was  %  inch.  Doc- 
tor Wright's  report  of  the  middle  turbinate  examination  was 
that  it  showed  a  moderate  grade  otitis  or  periotitis. 

Hig^h  Grade  Hyperplastic  Sphenoiditis — Blindness 

E.  H.  G.,  30  years  old,  consulted  me  September  21,  1916, 
referred  by  Dr.  J.  F.  Shoemaker.  He  had  an  optic  neuritis. 
His  vision  had  l)een  failing  three  weeks,  the  left  more  than  the 
right.  At  that  time  the  vision  of  the  right  side  was  13/100 ;  the 
left  3/200.  Examination  showed  a  very  high  grade  post-eth- 
moidal sphenoiditis  hyperplastic  dry.  He  never  had  had  head- 
ache. Tentative  treatment  failed;  and  on  September  22,  1916, 
the  left  siDhenoid  was  opened.  It  was  found  to  be  a  sub-divided 
cavity,  one  cell  above  the  other.  The  bone  was  very  thick  and 
very  hard. 

The  operation  made  no  improvement  in  the  eye  condition. 
A  short  time  later  the  cavities  closed  up.  They  were  re-opened, 
with  no  benefit  for  his  eye.  The  right  sphenoid  was  opened 
October  12,  1916. 

The  material  from  this  case  submitted  to  Dr.  AVright  for 
examination  engaged  his  attention  specially.  He  has  submitted 
a  full  report  in  the  introduction. 


204  HEADACHES    AND    EYE    DISORDERS    OF    jSTASAL    ORIGIjST 

This  is  a  case  whieli,  it  seems  to  me,  demonstrates  that 
wlien  the  hyperplastic  bone  process  is  of  high  grade,  such  as 
this,  we  fail  to  get  the  result  for  the  eye. 

I  have  record  of  many  others,  where  the  whole  hyper- 
plastic process  in  tlie  soft  parts  and  in  the  l)ones  l)oth  are  of 
nmch  lower  grade,  with  perfect  result.  His  was  the  liardest, 
thickest  bone  that  I  have  encountered  at  the  primary  operation. 
I  liave  operated  cases  that  have  been  operated  before,  either 
hy  myself  or  by  other  surgeons,  where  the  bone  formation  was 
hard  and  the  case  was  with  difficulty  handled. 

In  one  such  case  I  found  the  bone  so  thick  and  hard  that  it 
could  not  be  penetrated  by  the  little  angle  knife  that  it  is  my 
hal)it  to  use. 

That  was  a  headache  case  without  eye  involvement.  The 
fact  of  this  case  being  a  total  failure  for  the  relief  of  the  eye 
ti"ou])le  in  any  degree,  seems  to  me  to  follow  merely  the  path- 
ological findings  delineated  by  Dr.  Wright. 

Every  possible  line  of  investigation,  clinical  and  labora- 
tory, for  this  patient  was  negative,  including  a  spinal  fluid 
AVassermann  reaction. 

I  have  another  caso,  male,  52  years,  referred  by  Dr.  V.  P. 
Blair,  corresponding  with  this  in  all  particulars  in  which  there 
Avas  no  eye  involvement  but  great  lower-half  headache.  Open- 
ing the  sphenoid  did  not  help  the  case. 

Lower-half  Headache  and  Blepharospasm 

Mrs.  A.  B.  1).,  a  healthy  young  woman,  25  years  of  age, 
complaining  of  the  "lower-half  headache"  described  above, 
and  at  the  same  time  complaining  of  an  intractable  blepharo- 
spasm, with  great  lacrimation. 

Examination  revealed  an  inflamed  district  about  the  sphe- 
nopalatine foramen.  Injection  of  the  district  stopped  the  pain 
and  relieved  the  blepharospasm  and  the  lacrimation. 

The  case  has  stood  now  four  years  free  of  pain,  laci'ima- 
tion  and  blepharospasm. 

L.  A.  B.,  52  years  old,  consulted  me  December  7,  1915,  at 
the  suggestion  of  Dr.  John  Green,  Jr.,  for  severe  blepharo- 
spasm and  lacrimation  which  had  existed  8  months.  He  also 
showed  a  few  slight  opacities  in  the  vitreous.    Ophthalmological 


CASE    HISTORIES  205 

treatment  by  Dr.  Green  failed  to  control  tlie  spasm.  Xasal  ex- 
amination shoAvecl  a  hyperplastic  post-ethmoidal-splienoiditis, 
witliont  secretion.  Experiments  proved  that  cocainization  of 
the  ganglion  stopped  the  blepharospasm.  This  was  repeated 
many  times.  P'inally,  it  v.as  decided  to  inject  the  ganglia. 
February  22,  191(3,  the  right  ganglion  was  injected  with  cessa- 
tion of  the  blepharospasm  in  both  eyes  to  a  large  extent.  March 
6,  1916,  the  left  ganglion  A\'as  injected  with  total  comfort  and 
relief. 

This  patient  did  not  have  headache  at  any  time  of  his  life 
that  he  remem])ered.  Jle  shoAved  a  definite  hyperplastic  eth- 
moidal sphenoiditis  localized  about  the  sphenopalatine  foramen. 

It  wonld  have  been  impossible  to  have  connected  his  case, 
that  is,  of  cause  to  effect,  liad  H  not  been  that  I  had  three  times 
seen  marked  blepharospasm  accompanied  by  lacrimation  and 
lower-half  headache.  The  headache  was  the  index  to  the  cases. 
The  ganglion  was  injected  because  the  headache  Avas  controlled 
from  the  ganglion.  In  these  cases  the  blepharospasm  and  lac- 
rimation were  incidentally  relieved  Avith  the  headache.  I  there- 
fore put  this  ease  to  the  test  of  nasal  ganglion  cocainization  and, 
to  my  surprise  and  delight,  found  that  it  controlled  the  spasm. 

Although  there  were  no  other  manifestations  of  a  nasal 
ganglion  neurosis,  the  anatomical  lesion  at  the  proper  site  ac- 
companied by  the  control  of  cocainization  gave  me  the  feeling 
that  the  injection  of  tlie  ganglion  Avould  giA^e  the  result. 

He  has  noAv  surAaA^ed  three  seA^ere  coiyzas  Avithout  return 
of  the  spasm.  The  hyperplastic  post-ethmoidal  sphenoiditis  as 
the  result  of  the  injections  has  iuA^oluted  to  such  a  degree  as  to 
be  scarcely  recognizable  at  present.  His  A^sion,  Avliich  Avas  not 
quite  normal  before,  has  returned  to  normal. 

F.  B.,  38  years  old,  consulted  me  Xov.  1, 1917,  sent  l)y  Doctor 
F.  L.  Henderson,  Avho  had  exhausted  all  means  knoAvn  to  him 
for  the  relief  of  a  right-sided  blepharospasm  of  great  severity. 
Examination  shoAved  a  post-etlimoidal-sphenoidal  suppuration, 
Avitli  polyps  on  the  right  side.  Experiment  shoAved  that  cocain- 
ization of  the  right  nasal  ganglion  opened  his  right  eye  and 
relieved  the  blepharospasm  for  a  period  of  three  hours. 

It  Avas  therefore  decided  to  inject  the  nasal  ganglion  of  the 


206  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

riglit  side.  Tliis  was  done  three  times,  and  was  followed  by 
relief  of  the  sjiasm  for  three  to  six  hours. 

The  right  jDOst-ethmoidal-sphenoidal  ojDeration  was  per- 
formed Dec.  21,  1917,  and  also  relieved  the  spasm  for  a  few 
hours.  Treatment  of  the  sphenoid  cavity  was  followed  by  the 
cessation  of  the  suppuration,  and  disappearance  of  the  polyps; 
but  the  blepharospasm  remained.  Intra-sphenoidal  cocainiza- 
tion  relieved  the  spasm  for  three  to  six  hours. 

The  case  was  unsatisfactory,  at  least  for  the  blepharospasm, 
and  I  determined  to  open  the  sphenoidal  cavity  of  the  left  side. 
I  decided  this  because  I  remembered  that  nobody  could  tell  the 
sub-division  of  the  sphenoidal  body  prior  to  opening  it,  and  not 
always  then,  without  x-ray  plates  with  probes  in  situ.  I  felt 
that  the  irritation  might  come  from  the  left  sphenoidal  sinus. 

Prior  to  this,  the  experiment  with  the  left  nasal  ganglion 
was  performed,  and  was  found  to  give  longer  relief  from  the 
spasm  than  had  the  right  nasal  ganglion  or  the  right  sphenoidal 
sinus  experiment. 

I  then  elected  to  inject  the  left  nasal  ganglion.  This  has 
been  done  twice,  Avith  transitory  relief. 

April  20,  1918,  I  opened  the  left  post-ethmoidal-sphenoidal 
cells.    The  blepharospasm  is  unchanged. 

This  case  is  exceedingly  interesting,  bringing  np  the  ques- 
tion of  the  path  of  the  impulse  which  may  set  off  the  blepharo- 
spasm. 

I  had  assumed  that  it  was  sent  through  the  great  super- 
ficial petrosal  from  somewhere — the  seventh  nerve,  possibly, 
or  the  geniculate  ganglion;  but  that  it  would  be  of  the  same 
side.  The  fact  that  the  injection  of  the  left  ganglion  opened  the 
right  eye  is,  to  mj-  mind,  not  to  be  explained  at  j)resent. 

This  case  is  of  great  interest  in  connection  with  the  case 
of  L.  A.  B.  and  Mrs.  A.  B.  D.,  where  pronounced  blepharospasm 
was  relieved,  one  associated  with  the  loAver-half  headache,  Mr.  B. 
having  the  spasm  alone,  without  lieadache,  and  in  liotli  eyes. 
As  I  look  back  over  the  record  of  Mr.  B.  I  note  with  more  atten- 
tion than  was  given  in  the  beginning,  the  fact  that  the  injection 
of  the  first  ganglion  opened  both  eyes,  to  a  very  great  extent. 
The  case  Avas  not  completed,  hoAvever,  until  the  second  ganglion 
Avas  injected. 


CASE    HISTORIES  207 

Dilated  Pupil 

Miss  J.  W.,  age  44  years,  was  referred  to  me  Xov.  19,  1917, 
by  Dr.  A.  E.  Ewiiig,  whose  patient  she  had  heen  for  various 
eye  troubles  off  and  on  for  twent}^  years.  Dr.  Ewing's  state- 
ment was  that  for  three  months  she  had  noticed  an  enlarge- 
ment of  tlie  right  j)ui:)iL  She  also  gave  a  history  of  a  marked 
lower-half  headache,  right,  at  frequent  intervals  for  fifteen  years. 
The  headache,  which  has  been  a  great  trial  to  her  for  the  past 
six  years  has  been  accompanied  by  a  sense  of  "falling  back- 
ward." Dr.  Ewing  treated  her  enlarged  pupil  1)y  the  instillation 
of  pilocarpine.  The  pupil  would  contract;  but  did  not  remain 
contracted,  and  because  of  the  unsatisfactory  condition  he  refer- 
red her  to  me. 

Examination  of  the  nose  showed  a  very  clearly  marked 
hyperplastic  post-ethmoidal  sphenoiditis  without  secretion,  of 
the  right  side.  The  left  side  appeared  very  much  less  so,  which 
is  contrary  to  the  rule  for  these  cases;  the  lesion  usually  being- 
bilateral.  Treatment  of  the  sphenoid  accomi^lished  nothing. 
Jan.  24, 1918, 1  did  the  post-ethmoidal-sphenoidal  operation  upon 
the  right  side.  May  10,  1918,  she  reported  saying  that  she  was 
free  of  headache.  Examination  showed  that  her  pupil  which 
had  been  6  mm.  in  diameter  had  shrunk  down  to  4  to  4l^  mm. 
without  pilocarpine.  Syphilis  was  absolutely  excluded  in  this 
case  as  well  as  any  intra-cranial  lesion. 

The  case  is  to  me  unique  and  interesting  because  of  dilata- 
tion of  the  pupil  with  no  other  eye  disturbance.  It  is  interest- 
ing to  compare  it  with  H.  S.,  page  210,  where  the  paralysis  of 
accommodation  was  complete  but  no  dilatation  of  the  pupil  with 
it.  Unmixed  dilatation  of  the  pupil  is  rare  in  my  experience,  this 
being  the  only  case  where  the  disturbance  seemed  to  arise  from 
the  sphenoid. 

Pupil  and  Asthma 

Mr.  "VV.  C,  24  years  old,  very  strong,  large,  normal  man. 
My  patient  all  his  life,  whenever  a  rhinologist  was  needed  and 
intimately  known  to  me  in  every  way,  consulted  me  October  30» 


208  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN" 

1914,  for  a  slight  "cold  in  liis  head,"  which,  as  he  said,  he  would 
ordinarily  have  not  noticed;  but  for  some  special  (social)  rea- 
son he  was  anxious  "for  tomorrow"  to  be  relieved.  I  gave  him 
some  small  doses  of  calomel  and  told  him  to  omit  any  local 
treatment  because  the  local  disturbance  Avas  so  slight.  Two 
days  later  he  returned  stating  that  his  "cold"  had  taken  a  most 
unusual  turn — that  he  had  been  awakened  in  the  middle  of  the 
night  with  much  sneezing  and  watery,  rnnning  nose  accom- 
panied by  smothering  and  wheezing.  Examination  which  at  first 
was  negative  now  showed  well-marked  inflammation  of  the  mem- 
brane over  the  sphenopalatine  foramina.  He  had  no  other 
symptom  of  any  kind.  The  dyspnea  had  diminished  much.  Co- 
caine applied  to  the  foramina  relieved  it  altogether.  Phenol 
applied  to  the  district  prolonged  the  relief.  The  following  night 
he  had  a  slight  return  of  it.  The  inflammation  disappeared  from 
recognition  in  a  few  days  more,  with  recovery.  Six  weeks  later 
he  returned,  saying  that  he  again  had  1)een  awakened  in  the 
night  with  smothering,  wheezing  and  i-unning,  watery  nose. 
This  time  he  had  slight  pain  in  his  ears  also.  This  time  the 
attack  was  slight  with  slight  changes  locally,  the  same  as  above 
stated. .  Another  slight  recurrence  happened  four  weeks  later. 
Eight  weeks  after  last  note  he  developed  an  acute  sphenoidal 
empyema  with  dyspnea,  rales,  sneezing,  running,  watery  nose 
and  moderate  headache  in  ears,  occiput  and  neck.  This  again 
yielded  easily  to  treatment  but  did  not  get  entirely  well,  when 
after  six  weeks'  duration  he  developed  vertigo  and  mental  con- 
fusion to  a  most  annoying  degree,  accompanied  by  the  pecu- 
liar depressant  power  of  the  posterior  headache  (Vidian  neu- 
ralgia) to  a  marked  degree.  (His  disposition  is  normally  most 
cheerful  and  confident.)  (That  which  I  mention  as  vertigo  in 
these  cases  is  almost  never  a  sense  of  rotation.  It  is  a  sense  of 
the  earth  shifting  from  side  to  side  or  forward  and  back  or 
sinking  out  from  under  them.)  At  present  (May  15,  1915)  he 
is  well  again. 

In  one  of  his  years  at  college  in  Connecticut  he  had  had 
some  kind  of  a  coryza,  accompanied  by  more  sneezing  than  he 
thought  usual  with  his  coryzas,  but  this  is  the  only  part  of  the 
above  experience  that  was  not  new  to  him. 


CASE    HISTORIES  209 

Pupil 

J.  H.  A.,  37  years  old,  strong,  healthy  man,  had  never  had 
a  headache  in  his  life  that  he  remembered;  consulted  me  May 
27,  1910,  because  of  a  severe  left-sided  headache  which  had 
lasted  three  weeks,  lie  showed  a  left  sphenoidal  post-ethmoidal 
suppuration.  His  pain  A^'as  i)arietal  and  occipital,  for  the  most 
part,  and  irregular  in  severity,  sometimes  stopping.  AVhen  se- 
vere it  was  combined  with  pain  in  brow  and  upper  jaw.  He  was 
melancholic.  Treatment  was  not  satisfactory.  (He  was  com- 
pelled to  be  out  of  the  city  five  days  of  every  week.)  On  Octo- 
ber 12,  1910,  he  took  the  proposed  operation.  The  reaction  was 
severe.  He  was  free  of  symptoms  in  three  months.  March  4, 
1911,  he  consulted  me  because  of  a  coryza  with  pus  which  re- 
covered spontaneously.  January  6,  1912,  he  returned  because 
of  a  coryza  with  headache  which  did  not  recover  spontaneously. 
At  that  time  he  did  not  show  pus  in  the  sphenoid.  He  had  suf- 
fered greatly  from  intermittent  general  left  side  headache.  Be- 
lieving that  the  anaesthetic  qualities  of  carbolic  acid  could  be 
soaked  into  the  nerve-trunks  in  juxtaposition  to  the  sphenoid, 
I  filled  the  cavity  witli  ]  per  cent  solution  in  oil,  which  stopped 
the  pain  in  six  hours.  The  cavity  was  filled  once  a  week  for 
three  weeks,  when  he  seemed  well,  and  remained  so  until  the 
next  coryza,  six  weeks  later,  which  was  controlled  by  1  per  cent 
carbolic  acid  in  oil.  The  left  pupil  is  larger  than  the  right  dur- 
ing his  attacks,  and  use  of  his  eye  is  somewhat  difficult  at  those 
times.  He  says  his  pupils  were  always  equal  before  his  head- 
ache l)egan  and  are  so  now  in  the  intervals  between  coryzas 
when  he  is  well  of  headache.  This  case  has  so  far  not  behaved 
as  a  hyperplastic  ethmoiditis.  In  the  inflammatory  attack  it 
shows  only  redness  Avith  little  s^^'elling•,  and  sometimes  x)us. 

Mrs.  B.  C,  aged  33  3'ears,  in  1913  consulted  me  because  of 
obscure  headache.  She  had  clearly  a  vacuum  frontal  headache, 
for  which  the  anterior  three-quarters  of  the  middle  turbinate 
Avere  remoA^ed  Avith  full,  satisfactory  result.  She  still  has  at 
times  headache  Avhich  apparently  proceeds  from  the  nasal  gan- 
glion on  the  right  side.  It  is  controlled  by  cocainization  of  the 
ganglion,  and  shoAvs  at  that  site  inflammation  oA'er  the  spheno- 
palatine foramen.    Cocainization  of  the  ganglion  in  this  patient 


210  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

is  often  followed  by  dilatation  of  the  pnpil  of  that  side  appar- 
ently indicating  the  reverse  action  of  cocaine,  that  is,  irritation 
to  the  sympathetic  in  contradistinction  to  the  case  jnst  reported, 
where  it  was  evident  that  complete  paralysis  took  place 
(Mrs.  F.). 

Mrs.  C.  F.,  35  years  old,  consulted  nie  Jannary  1,  1918,  at 
the  snggestion  of  Dr.  Fayette  Ewing.  She  had  sntfered  vio- 
lently from  headache  a  large  part  of  her  life.  Dr.  Ewing  had 
fonnd  some  disease  of  the  ethmoid  on  the  left  side,  and  had 
curetted  the  capsnle  of  the  ethmoid  for  that  reason.  She  con- 
tinued to  have  great  headache;  and  as  he  was  about  to  depart 
for  service  in  the  National  Army,  he  put  her  in  my  charge.  In 
the  effort  to  localize  some  starting  point  for  the  pain,  I  cocain- 
ized the  ganglion  of  the  right  side  at  a  time  when  the  headache 
was  on  the  right  side.  The  headache  was  stopped;  but  as  an 
effect  of  cocainization  the  right  eyelid  drooped  very  percepti- 
bly, to  obscure  probably  half  of  the  blepharal  fissure,  and  the 
pupil  contracted  to  be  one-half  of  the  size  of  the  fellow  of  the 
opposite  side.  The  case  presents  this  interesting  phenomenon: 
that  through  the  nasal  ganglion  in  this  case  must  pass  a  large 
part  of  the  s;\rmpathetic  supply  which  goes  for  the  elevation  of 
the  eyelid  and  to  the  pupil. 

Paralysis  of  Accommodation 

H.  S.,  35  years  old,  large,  very  strong,  healthy  man,  re- 
ferred by  Dr.  F.  L.  Henderson,  November  25,  1914,  for  com- 
plete paralysis  of  accommodation  L.  eye  of  six  months'  stand- 
ing. He  had  a  sphenoiditis  of  low  grade  with  moderate  hyper- 
plasia and  very  scant  mucopurulent  or  mucous  secretion.  Post- 
ethmoidal-sphenoidal  operation  November  30,  1914.  Accom- 
modation began  to  return  one  month  later  and  in  three  months 
had  returned  complete.  The  bone  has  not  yet  been  submitted 
to  Dr.  Wright. 

Asthma 

iMiss  L.,  aged  60  years,  was  sent  to  me  by  Doctor  Walter 
Baumgarten  on  May  28,  1914,  because  of  an  intractable  asthma 
of  fifteen  years'  standing.    Examination  of  the  nose  showed  a 


CASE    HISTORIES  211 

post-etlimoiclal  si^lienoiditis,  accompanied  by  much  swelling,  and 
polyps,  and  very  little  secretion. 

Effort  was  made  to  control  the  sitnation  from  the  nasal 
ganglion.  This  failed.  October  2, 1915,  the  sphenoid  was  opened 
on  the  left  side,  followed  by  relief  of  the  asthma  and  general 
betterment  of  her  physical  condition,  Avhich,  up  to  that  time, 
was  exceedingly  bad. 

The  woman  is  still  far  from  robust;  but  she  is  in  comfort 
and  fairly  good  health.  The  case  is  interesting  as  an  asthma 
of  long  standing,  of  sphenoidal  origin.  It  is  aJso  interesting 
from  a  therapeutic  standx)oint.  T  have,  however,  some  other 
cases  of  more  or  less  this  origin  and  duration,  which  at  present 
stand  as  therapeutic  failures.  They  have  chest  involvement  in 
addition  to  the  sphenoid. 

Mrs.  A.  H.,  35  years  old,  consulted  me  on  April  24,  1916, 
saying  that  she  had  lower-half  headache,  and  that  she  had  ' '  hay 
fever  in  season ;  but  it  lasted  all  the  year  round."  It  was  worse 
from  August  15,  on  till  frost.  Examination  showed  a  well- 
marked  post-ethmoidal  sphenoiditis,  localized  at  the  site  of  the 
ganglion.  Cocainization  of  the  ganglion  stopped  the  sneezing, 
running;  and  on  one  occasion  a  low  grade  dyspnea,  Avith  dry 
rales,  was  also  controlled  by  cocainization  of  the  nasal  gan- 
glion. She  was  subject  to  frequent  (every  Aveek)  asthmatic  at- 
tacks. They  were  each  time  controlled  from  the  ganglion,  more 
or  less.    This  led  me  to  inject  the  ganglia. 

At  the  end  of  the  year  now  she  has  been  without  headache. 
She  says  that  she  has  been  well,  except  on  one  occasion,  when 
she  contracted  a  bad  cold  in  her  nose,  and  she  had  asthma  for 
one  night,  without  any  nausea. 

She  passed  through  the  hay  fever  season  Avithout  asthma  or 
headache,  except  for  slight  symptoms  extending  oA^er  ten  days. 

January  15,  1918,  she  consulted  me  because  of  a  severe 
coryza,  Avhich  made  a  little  headache  and  asthma. 

This  case  is  interesting  because  of  the  long-standing  head- 
ache associated  Avith  asthma.  It  shoAvs  also  that  the  symptoms 
may  arise  from  A'arious  irritants;  to  Avit,  autunmal  hay  fe\^er 
and  AvhateA^er  may  make  a  coryza  in  the  region  of  the  nasal 
ganglion.    Seemingly,  the  lesion  of  the  nasal  ganglion  originated 


212  HEADACHES    AND    EYE    DISORDERS    OF    NASAL   ORIGIN 

from  a  low  grade  pathological  process  that  was  controllable  by 
one  injection. 

Ophthalmoplegic  Migraine  Vertigo 

G.  L.  A.,  67  years  of  age,  had  suffered  from  dizziness, 
which  lie  describes  as  "a  shifting  of  the  earth  from  side  to 
side,"  for  18  months.  He  also  suffered  at  intervals  with  what 
he  describes  as  a  crossing  of  his  eyes,  accompanied  by  a  total 
obscuring  of  his  vision.  These  attacks  last  for  a  few  minntes 
each  only.  Seldom  did  he  have  a  slight  lower-half  headache. 
His  case  had  been  investigated  extensively  in  all  departments, 
and  no  cause  could  be  assigned  for  his  trouble.  Examination  of 
his  nose  revealed  a  bright  red  color  throughout,  but  particularly 
through  the  sphenoethmoidal  district.  Treatment  was  unsat- 
isfactory, and  finally,  on  April  5,  1917,  the  sphenoid  was  opened. 

After  the  operation  he  Avas  free  of  dizziness  and  eye  dis- 
turbances for  six  months.  A  coryza  re-established  symptoms 
to  some  extent.    His  condition  in  general  is  improved. 

This  case  is  of  interest  because  of  the  color  alone  lieing  the 
only  indication  of  sphenoidal  troul)le. 

The  dizziness  is  markedly  improved;  and  the  attacks  of 
strabismus — ''blindness" — have  ceased,  with  one  exception,  and 
that  at  the  time  of  a  coryza.  This  history  sounds  much  like  oph- 
thalmoplegic migraine.  I  have  occasionally  seen  dizziness  in 
these  cases  described  as  a  falling  sensation. 

Third  and  Sixth  Paralysis — Ophthalmic  Migraine 

A.  A.,  22  years  old,  normal,  referred  by  Dr.  A.  E.  Ewing. 
October  6,  1914.  My  diagnosis :  Sphenoidal  suppuration,  R. 
Dr.  Swing's  report:  The  3^oung  woman,  22  years  of  age,  a 
week  previous  to  the  examination  noticed  that  everything  ap- 
peared double,  with  considerable  headache.  At  the  time  of 
the  first  examination,  October  2,  the  vision  in  the  right  eye 
varied  from  20/38  to  20/24;  in  the  left  it  Avas  20/20.  In  the 
right  eye  the  vision  could  be  improved  to  20/20  ])y  a  weak  con- 
cave lens.  The  muscular  disturbance  consisted  of  a  slight  nys- 
tagmus when  looking  strongly  up"\\^ard  or  downward.  On  the 
6th  there  was  positive  restriction  in  the  motion  of  the  right  eye 
outward  and  a  diplopia  which  was  corrected  by  a  prism  of  25^ 


CASE    HISTORIES  213 

base  outward  over  the  right  eye;  left,  20/24;  fields  normal;  each 
fundus  normal.  The  nasal  examination,  made  the  same  day, 
revealed  suppuration  from  the  right  sphenoidal  sinus.  Two 
days  later  this  sinus  was  opened.  On  the  26th  the  recovery  had 
so  far  progressed  that  the  diplopia  was  corrected  by  a  prism 
of  7°  base  outward  0.  1). ;  the  vision  had  risen  to  20  20,  and  was 
the  same  with  +0.37  sph.  Three  weeks  later  binocular  vision 
had  become  re-established  and  the  eyes  were  used  freely  and 
comfortably,  the  vision  in  each  eye  being  20/20+  Avithout  glasses. 

This  case  is  of  especial  interest  because  of  the  diplopia  that 
was  at  tirst  indefinite,  the  lowering  of  the  vision  in  the  right  eye. 
the  accommodative  spasm  and  the  nystagnms  in  extreme  up- 
ward and  downward  exertion,  all  of  which  combined  Avas  an 
evidence  of  a  general  slight  oculomotor  and  optic  nerve  toxemic 
involvement.  Later  the  abducens  became  most  affected,  prob- 
ably by  reason  of  gravity  of  the  toxic  substance  and  because 
of  proximity  to  the  infected  region,  the  al^ducens  being  the  low- 
est of  the  oculomotor  nerves  in  their  passage  through  the  sphe- 
noidal fissure,  and  nearest  to  the  post-ethmoidal  and  sphenoidal 
sinuses,  as  well  as  nearest  to  the  sphenoidal  sinus  in  its  course 
over  the  clivus  and  around  the  posterior  clinoid  process  of  the 
sphenoid  after  its  exit  from  the  dura  mater. 

In  addition  to  tlic  actual  h^sson  taught  in  this  instance, 
there  is  another  presuinal)le  one,  which  is  that  many  of  the 
hysterical  amblyopias,  and  many  of  the  temporary  indefinite 
muscular  anomalies  and  obscure  disturbances  of  the  accommo- 
dation ordinarily  accredited  to  hysteria,  may  really  be  tox- 
emias due  to  nasal  infection.  This  case  corresponds  with  the 
ophthalmoplegic  migraines. 

October  8,  1914,  post-etlimoidal-sphenoidal  operation.  Dr. 
Wright's  report  of  changes  in  post-ethmoidal-sphenoidal  wall: 
The  mucous  membrane  of  the  sphenoidal  wall  in  this  case  is  the 
site  of  some  fibrous  hyperplasia  and  of  some  edema.  There  are 
small  patches  of  connective-tissue  in  which  this  hyperplasia  is 
quite  marked  around  moderate-sized  arterioles.  There  does 
not  seem  much  bone  change. 

Turbinate:  This  consists  of  edematous  connective-tissue 
beneath  the  epithelium  which  is  not  much  altered.  The  veins 
and  venules  are  dilated  and  full  of  blood  and  serum,  but  their 


214  HEADACHES    AXD    EYE    DISORDERS    OF    N^ASAL    ORIGIX 

walls  are  not  markedly  thickened.  The  acini  of  the  glands  are 
somewhat  dilated.  There  is  not  much  prodnction  of  new  con- 
nective-tissue nor  l3one  lesion.  The  case  is  evidently  one  of  su])- 
ncute  inflammation. 

The  wound  was  uneventful  in  healing. 

In  this  case  the  process  had  lasted  probably  only  a  short 
time.  The  status  of  October  6th  was  precipitated  by  an  accute 
or  sub-acute  inflammation  upon  the  older  process. 

Professional  Cramp 

Mrs.  S.  S.,  40  years  of  age,  had  suffered  violent  "'lower- 
half  headaches"  (nasal  ganglion  headaches)  all  of  her  life,  as 
far  as  her  memory  went.  For  the  past  ten  3'ears  she  has  had 
added  to  the  picture  such  pain  on  writing,  as  to  make  this  dif- 
ficult and  pass  as  a  writer's  cramp  of  such  severity  that  the 
only  writing  she  has  been  able  to  do,  and  that  with  difficulty, 
has  been  to  sign  checks  for  the  household  expenses. 

Examination  revealed  tluit  the  sphenopalatine  foramen  dis- 
trict was  inflamed  for  some  considerable  distance  around;  that 
is,  she  has  a  post-ethmoidal  sphenoiditis  hyperplastic;  but  the 
pain  was  controlled  from  application  of  cocaine  to  the  ganglion. 

For  this  reason  I  elected  to  inject  the  ganglion  rather  than 
do  the  post-ethmoidal-sphenoidal  operation. 

Each  ganglion  had  now  been  injected  three  times,  with  con- 
siderable relief  from  the  pain;  and  from  the  first  injection  of 
the  right  side,  the  writer's  cramp  had  been  alisent.  She  is  able 
to  write  as  much  as  any  other  woman. 

In  one  severe  coryza,  the  cramp  returned  for  the  length  of 
one  week,  when  it  passed  off  spontaneously. 

A  coryza  makes  headache  often  severe  while  it  lasts  and 
in  the  height  of  the  i^ain,  that  entire  side  of  the  body  becomes 
tender  to  touch. 

This  case,  like  some  others  reported  here  raises  the  ques- 
tion of  pain  sense  transmission  and  how  far  can  it  go;  with 
the  suggestion  that  it  is  accomplished  by  the  sympathetic. 

Mrs.  S.  A.,  30  years  old,  consulted  me  January,  1913,  at  the 
behest  of  Dr.  M.  A.  Bliss.  She  had  had  a  cyclical  nasal  ganglion 
neuralgia,  left,  severe  for  eight  years.     She  was  a  professional 


CASE    HISTORIES  215 

violinist  for  the  concert  stage.  The  pain  interfered  with  her 
practice  nntil  she  was  compelled  to  consult  pln'sicians.  It  was 
declared  to  be  a  "professional  (^ramp"  by  the  noted  neurologists 
of  Eussia,  Germany,  France,  and  England.  She  was  advised  to 
stop  playing  the  violin,  which  was  "as  dear  as  life  itself"  to 
her.  This,  together  with  the  depressant  nature  of  the  Vidian 
pain  made  a  state  of  mind  for  her  exceeding  hard  to  bear.  The 
anterior,  maxillary  part  of  the  pain  was  controlled  by  the  first 
injection  of  pheiiol-alcohol.  The  posterior  (Vidian)  pain  re- 
quired a  second  injection.  For  a  year  and  a  half  she  has  been 
free  of  pain  except  at  the  time  of  a  coryza,  which  was  of  short 
duration.  She  is  able  to  practice  and  play  in  concerts  and  do 
an  unusual  amount  of  teaching  (10  hours  a  day). 

I  have  seen  a  bilateral  nasal  ganglion  neuralgia  pronounced 
a  "piano  cramp"  for  the  same  reasons  that  led  to  the  error  in 
this  case. 

J.  A.,  20  years  old,  strong,  healthy,  consulted  me  April,  1911. 
He  had  a  well-marked  nasal  ganglion  neuralgia,  left,  with  con- 
stant pain,  sometimes  less  and  sometimes  more.  He  was  an  en- 
thusiastic golf  player.  It  was  declared  to  be  a  "golf  arm"  by 
his  physicians  (internists  and  surgeons).  Three  injections  of 
phenol-alcohol  were  required  before  relief  was  complete  and  per- 
manent. He  has  had  recurrences  from  coryzas  which  have  not, 
however,  needed  treatment.  He  has  been  free  of  pain  for  five 
years. 

Sympathetic  Cases 

Mrs.  M.  M.  M.,  67  years  of  age,  frail,  but  otherwise  in  good 
health,  consulted  me  Marcli  10,  1915.  For  sixteen  years  she  had 
had  a  slight  serous  secretion,  with  great  redness  of  the  external 
nose. 

Examination  revealed  an  inflamed  area  about  the  spheno- 
palatine foramen.  Cocainization  relieved  the  serous  discharge, 
and  caused  the  redness  and  swelling  of  the  external  nose  to 
disappear  for  varying  periods  of  three  hours  to  three  days. 
Injection  of  the  ganglion  of  each  side  was  followed  by  a  ces- 
sation of  the  serous  discharge,  and  a  return  of  the  external  nose 
to  normal  color  and  proportion.    The  color  was  as  nearly  blood- 


216  HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIISr 

red  as  swollen  tissue  may  ever  appear.  The  degree  of  swelling 
was  between  15  and  20  per  cent,  I  should  say;  in  other  words, 
there  was  acne  rosacea  of  15  years'  standing,  which,  I  am  snre, 
in  the  mind  of  the  dermatologist,  might  easily  have  been  sup- 
posed to  have  been  made  by  the  serous  discharge. 

I  have  a  great  many  other  cases,  where  the  serous  dis- 
charge is  cpiite  profuse,  but  in  which  no  rosacea  developed. 

I  have  also  seen  many  times,  with  an  acute  condition  in- 
volving the  sphenopalatine  district,  complete  and  perfect  ex- 
ternal red  and  swollen  noses,  where  the  serous  discharge  had 
not  had  time  to  effect  any  skin  irritation.  In  this  case  there 
was,  as  far  as  I  could  make  out,  no  skin  irritation.  It  was  a 
state  of  red  swelling  without  inflammatory  skin  involvement. 

Mr.  G.  M.  L.,  lawyer,  35  years  old,  strong  and  in  every  way 
normal  man.  I  should  classify  this  patient  as  unusually  "nor- 
mal;"  beside  physical  well-being  he  has  no  idiosyncrasies  knoAvn. 
He  is  not  sensitized  along  any  line  now  known.  He  does  not 
have  hay  fever  or  horse  asthma.  He  consulted  me  December 
15,  1914,  for  what  he  said  was  the  "worst  cold"  he  had  ever 
had,  of  three  days'  standing.  He  did  not  have  headache,  but 
his  mental  processes  were  so  slow,  together  Avith  such  a  ten- 
dency to  confusion  that  he  was  unable  to  do  his  work  in  the 
courts  with  justice  to  himself  or  client.  He  complained  also  of 
weariness  but  did  not  feel  sick  enough  to  take  to  his  bed.  Ex- 
amination showed  a  pronounced  post-ethmoidal-sphenoidal  sup- 
puration R.  and  L.  Anterior  two-thirds  of  nose  normal.  He 
responded  rapidly  to  acetphenetidin  internally  and  local  cleans- 
ing and  draining.  In  five  days  he  said  he  felt  well  enough  to  go 
into  court  again,  and  he  did  so,  everything  being  satisfactory. 
I  did  not  see  him  again  for  two  weeks,  Avhen  he  again  presented 
himself  for  examination,  saying  he  felt  well.  The  evidence  of 
the  local  trouble  had  nearly  disappeared.  I  asked  him  to  return 
again  for  examination  in  three  Aveeks  and  to  continue  the  use 
of  his  cleansing  nasal  solution.  In  tAvo  Aveeks,  liOAveA^er,  he  pre- 
sented himself,  saying  that  Iavo  days  before,  Avhile  seated  at  his 
fireside,  reading,  at  9  p.m.,  he  Avas  sudderdy  seized  Avith  fre- 
(iu(4it  sneezing,  nasal  obstruction,  profuse  hot,  watery  secretion 
and  tearing  so  profuse,  as  he  expressed  it,  that  in  al)out  two 
hours  all  of  the  handkerchiefs  of  the  familv  had  been  used,  as 


CASE    HISTORIES  217 

well  as  all  the  face  towels,  and  he  was  driven  to  use  the  bath 
towels,  and  then  used  nearly  all  the  supply  of  them.  And,  that 
when  he  was  not  wiping  his  nose  he  was  busy  wiping  his  eyes. 
AVith  these  symptoms  Avas  a  photophobia  which  rapidly  in- 
creased until  he  was  compelled  to  go  to  bed  and  put  out  his 
light,  but  even  then  enough  light  from  the  gas-lighted  street 
entered  his  room  to  ''hurt  his  eyes,"  and  finally  he  Avas  com- 
pelled to  Avrap  them  in  a  wet  towel  to  exclude  every  trace  of 
light.  He  remained  in  bed  in  this  condition  two  nights  and  a 
day.  At  this  time  he  again  presented  himself  with  a  rhinorrhea 
which,  although  profuse,  Avas,  as  he  said,  very  much  better. 
His  eyes  were  red  and  itching  and  streaming  tears,  his 
pupils  were  Avidely  dilated,  with  still  some  photophobia,  his  lids 
were  staring  wide  open  and  his  eyes  seemed  to  protrude  slightly, 
his  external  nose  Avas  cpiite  red  and  markedly  SAvollen  and 
slightly  chapped  from  Aviping.  He  said  his  chest  felt  "full." 
His  Avindpipe  and  into  the  bifurcating  bronchi  Avas  bright 
blood  red.  No  rales  in  chest ;  temperature  normal.  He  said 
he  thought  that  if  the  local  nose  and  eye  troulile  could  be 
stopped  he  Avould  feel  Avell.  I  cocainized  the  nose  anteriorly, 
without  effect,  and  then  cocainized  the  ganglia  by  painting 
the  sphenopalatine  foramina  i/o  drop  saturated  Avater  solu- 
tion 90%  +.  This  Avas  repeated  three  times  at  ,^ve-minute 
inter\'als  Avith  marked  benefit  each  time.  The  nasal  obstruction, 
rhinorrhea,  lacrimation,  mydriasis,  rosacea,  and  appearance  of 
exophthalmos  vanished.  He  looked  normal,  and  said  he  felt  so. 
There  AA'as  a  slight  return  of  the  symptoms  in  24  hours,  Avhich 
again  yielded  to  cocaine,  and  again  in  another  24  hours.  He 
then  remained  free  of  symptoms  imtil  February  10,  1915,  Avhen 
he  returned  because  of  another  "cold"  (coryza),  presenting 
again  the  aboA^e  descriljed  picture,  much  milder,  hoAve\'er,  in 
eA'ery  Avay;  but  this  time  accompanied  by  pain  in  his  ear,  mas- 
toid, occiput,  neck,  shoulder  blade,  and  shoulder,  not  A'ery  scA^ere. 
This  time  he  had  slight  dyspnea  and  a  fcAv  dry  rales  in  the  first 
24  hours.  This  time  he  did  not  shoAv  post-ethmoidal-sphenoidal 
suppuration  but  only  congestion  of  the  olfactory  fissure. 

This  case  is  at  once  recognized  as  the  one  from  Avliich  the 
aboA^e  description  Avas  taken.  Many  tiuK^s  in  the  course  of  20 
A'ears  haA^e  I  heard  this  state  described  by  ])atients  almost  al- 


218  HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN 

ways  emphasized  by  the  statement,  "No  physician  ever  thinks 
I'm  truthful  when  I  tell  this.  They  (the  coryzas)  are  awful!" 
Many  times  have  I  tried  to  have  the  patient  return  to  me  in  the 
midst  of  the  attack.  They  are  not  very  frequent,  however,  and 
the  patients  usually  describe  them  as  occurring  at  long  intervals 
and  often  prostratiiig  him,  or  milder  attacks  being  of  short  (24 
hours)  duration  he  may  not  recall  his  promise  soon  enough. 
However,  since  this  case  impressed  itself  on  me  I  have  learned 
to  recognize  the  milder  types  which  prove  to  be  rather  fre- 
quent, Tliey  may  have  little  or  no  rosacea,  or  little  or  no  photo- 
phobia. The  rhinorrhea  is  more  profuse  and  sometimes  the 
only  symptom. 

H.  G.  L.,  13  years  old,  small  boy,  under  strength.  Consulted 
me  November,  1914.  He  had  a  profuse  rhinorrhea  with  great 
morning  sneezing,  accompanied  by  great  morning  photophobia 
and  moderate  exophihalmos.  He  has  a  high  grade  hyperplastic 
sphenoiditis.  Sometimes  he  has  slight  asthma.  Treatment  of 
his  nose  has  thus  far  relieved  the  photophobia  and  nearly  all 
the  sneezing.  His  eyes  are  in  Avhat  seems  to  be  normal  position 
in  his  sockets. 

Mrs.  E.  C,  30  years  old,  became  my  patient  February  10. 
1907,  for  acute  empyema  of  right  frontal  sinus,  which  recovered 
as  an  ordinary  severe  coryza.  It  recurred  several  times  with 
much  pain,  and  in  November,  1908,  I  removed  the  middle  tur- 
binate liigh  up,  which  gave  a  large  outlet  to  the  sinus  and  cessa- 
tion of  all  symptoms.  A  low  grade  hyperplastic  process  in  the 
anterior  ethmoid  and  frontal  region  existed  then,  or  was  started 
that  year,  which  has  extended  backward  to  involve  the  post- 
ethmo-sphenoidal  region.  Great  pain  of  maxillary  and  Vidian 
distribution  began  to  develop,  occasionally,  in  1911  and  1912, 
and  became  more  frequent  and  severe.  Occasionally  a  coryza 
made  post-ethmo-sphenoidal  suppuration.  A  Hajek  post-ethmo- 
sphenoidal  operation  was  done  on  the  same  (right)  side  in 
1913,  followed  by  irregular  intermittent  treatment  with  marked 
relief  from  pain.  Later,  in  1913,  she  began  to  complain  of  con- 
stant slight  watery  discharge  from  left  nostril,  which  was  proven 
to  be  secretion  from  membrane  in  general.  Tlie  sphenopalatine 
foramen  district,  however,  began  to  show  changes  and  treat- 


CASE    HISTORIES  219 

ment — silver,  acetic  acid,  cocaine — was  directed  to  it.  The  se- 
cretion continued  and  increased.  She  had  an  occasional  ganglion 
neuralgia  of  the  left  side.  On  November  15,  1914,  I  injected  the 
nasal  ganglion,  left,  with  phenol-alcohol,  since  which  she  has 
been  free  of  d'lscliarge  and  has  not,  so  far,  had  a  recurrence  of 
pain. 

Ophthalmic  Migraine 

S.  A.,  23  years  old,  normal  but  not  up  to  full  strength,  con- 
sulted me  Octol)er  25,  1912.  He  showed  at  that  time  a  hyper- 
plastic post-ethmoiditis  most  marked  over  left  sphenopalatine 
foramen.  He  had  had  for  10  years  a  severe  cyclical  nasal  gan- 
glion neuralgia,  left,  recurring  once  in  three  to  six  weeks.  The 
attack  Avas  always  accompanied  by  scotoma  scintiUans  amhli/- 
opia,  lower-half  headache,  vomiting,  aphasia  and  hemi-paresis 
of  short  duration.  I  injected  the  left  ganglion  three  times  with 
phenol-alcohol.  P'or  two  years  he  has  been  free  of  the  attacks 
except  that  a  severe  coryza  re-establishes  the  SA^ldrolne  tempo- 
rarily. 

Mrs.  M.  H.,  27  years  old,  has  had  for  ten  years  a  recurrent 
life  ophthalmic  migraine  at  irregular  (months)  intervals.  Ex- 
amination shows  a  post-ethmoiditis  left  low  grade  which  sup- 
purates with  a  coryza.  Observation  reveals  that  the  attack  is 
uniformly  established  by  a  coryza.    At  other  times  she  is  well. 

Mrs.  L.  E.,  26  years  old,  referred  by  M.  H.  Post,  September 
24,  1913,  with  the  report  that  her  eyes  Avere  normal.  She  had 
a  complete  right-sided  oplithalmic  megrim,  7  years'  duration, 
scotoma  scintillans,  violent  headache  (loAver  half),  nausea  and 
vomiting,  hemianopsia  anil)lyopia.  The  attack  came  every  four 
days,  approximately.  My  diagnosis:  Marked  hyperplastic 
sphenoiditis,  R.  She  grcAv  slowly  worse;  the  attacks  became 
more  frequent  and  more  severe.  Post-ethmoidal-sphenoidal 
operation  R.  January  2,  1914.  Dr.  Wright's  report  of  the 
changes  in  the  sphenoidal  wall.  Here  is  a  very  marked  involve- 
ment of  the  bony  structure.  The  periosteum  is  greatly  inflamed 
and  there  is  a  quite  marked  hyperplasia  of  the  lione.  The 
soft  parts  over  it  are  in  a  state  of  chronic  inflannnation.     The 


220  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

middle  tiir])inate  sIioavs  only  a  moderate  cliaiige  in  the  soft  parts 
and  the  bone  is  not  much  involved.  The  surface  epithelium  is 
also  not  much  involved. 

She  became  better  as  soon  as  the  wounds  were  healed  and 
the  reaction  totally  subsided;  and  has  since  then  been  for  the 
most  part  well,  A  coryza  re-establishes  the  syndrome,  but  it 
usually  does  not  need  local  treatment. 

In  another  complete  ophthalmic  megrim  (Mrs.  D.,  30  years 
old)  the  mucous  membrane  in  the  sphenoidal  sinus  at  the  time 
of  operation  showed,  with  Plolmes'  pharyngoscope,  a  most 
marked  thickening  and  induration  with  dryness  and  pallor.  Dr. 
Wright's  report  of  the  changes  in  the  sphenoidal  wall  micro- 
scopically are :  The  inflammatory  changes  here  are  quite 
marked.  There  is  a  considerable  degree  of  inflammation  of 
the  periosteum  and  some  evidence  of  hyperplasia  of  the  bones 
while  the  soft  parts  over  it  are  markedly  involved  in  the  chronic 
inflammatory  process. 

This  was  a  bilateral  case,  one  side  only  is  so  far  operated 
(15  mos.).    There  has  been  only  moderate  betterment  clinically. 

These  cases  to  me  show  the  difference  in  prognosis  between 
a  post-ethmoidal  and  a  sphenoidal  lesion.  Mrs.  L.  E,  had  a  mi- 
graine exploded  from  the  nasal  ganglion.  In  Mrs,  D.  it  began 
probably  in  the  nerve-trunks. 

Miss  E,  S,  consulted  me  Oct.  15,  1916,  because  of  great 
headache  w^hicli  was  more  or  less  constant.  She  complained  also 
of  an  admixture  of  some  other  kind  of  headache  that  came  on 
at  intervals  of  tw^o  to  three  weeks,  characterized  by  scotoma 
scintillans  and  vomiting. 

Examination  showed  a  profuse  right-side  sphenoid  sup- 
puration which  was  operated,  with  relief  of  the  suppuration; 
also  the  relief  of  the  headache  which  had  been  more  or  less  con- 
stant. 

However,  the  other  headache  she  described  has  confined  un- 
changed. Her  description  is  that  she  feels  something  which 
starts  in  the  instep  of  her  right  foot,  and  then  extends  to  the 
right  half  of  her  body,  including  her  head,  with  violent  head- 
ache and  blindness. 

This  case  seems  to  me  to  be  one  of  rare  pure  migraine — 


CASE    HISTORIES  221 

rare  in  my  experience,  where  most  are  independent  of  tlie  nasal 
condition. 

Scotoma  Scintillans 

F.  L.  H.,  aged  50  years,  consulted  me  in  1905  because  of 
severe  headache  that  kept  him  awake,  usually  sitting  up,  through 
six  niglits  out  of  the  week. 

Examination  showed  an  intensely  inflamed  post-ethmoidal- 
sphenoidal  district,  without  hyperplasia  or  pus. 

Treatment  of  his  nose  helped  little  or  none.  He  was  p)laced 
in  the  charge  of  all  varieties  of  specialists  of  the  first  rank  in 
all  parts  of  the  country.  All  manner  of  diet  was  instituted, 
and  every  investigation  that  modern  laboratories  are  capable 
of  making  was  exhausted.  He  finally  became  so  bad  that  he 
consented  to  the  post-ethmoidal-sphenoidal  operation,  which  was 
done  in  1909  on  the  right  side. 

It  has  afforded  sufficient  relief  to  permit  of  his  attending 
to  his  arduous  duties,  the  headache  rarely  being  so  bad  that  he 
is  helpless  from  it.  Much  of  the  time  he  is  free  of  pain  al- 
together. A  coryza  uniformly  makes  very  considerable  pain 
for  him. 

This  case,  aside  from  the  headache,  at  the  greatest  inten- 
sity becomes  l^liiid,  develops  a  scotoma  scintillans,  which  inca- 
pacitates him  totally.  

This  is  in  great  contrast  to  S.  A.,  reported  above,  where 
the  type  is  that  of  pure  ophthalmic  migraine,  which  hegius  by 
scotoma  scintillans. 

Optic  Neuritis 

V.  S.,  age  22,  was  sent  to  me  by  Doctor  Adolph  Alt  in  1914. 
He  had  a  low  grade  optic  neuritis  of  recent  origin.  Examina- 
tion of  the  nose  showed  a  hyperplastic  sphenoiditis,  low  grade 
with  an  acute  process  engrafted  on  it.  Forcible  injections  of 
carbolized  oil  to  the  olfactory  fissure  began  to  help  at  once. 
In  three  weeks  the  optic  neuritis  had  subsided  and  his  eye  was 
normal  again  and  since  that  time  there  has  not  been  another 
attack.  The  case  is  interesting  to  me,  showing  how  sometimes 
an  excellent  result  is  ol)tained  for  small  effort. 


222  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

E.  D.,  strong,  healthy  man,  24  years  old,  referred  by  Dr. 
John  Green,  Jr.,  and  Dr.  Lonis  nempelmann.  My  diagnosis: 
Hyperplastic  sphenoiditis  with  subacute  suppuration.  Dr. 
Green's  report:  ''Seen  first  Feb.  20,  1914.  Right  vision  6/5; 
left  vision  6/5+.  For  five  years  complained  of  lower-lialf  head- 
aches and  temporary  blind  spells. 

''Ophthalmoscope  showed:  right,  nmshroom-like  swelling  of 
disc  with  swelling  starting  abruptly  at  margin  and  mounting  up. 
Margins  very  much  veiled,  veins  a  little  dilated  and  tortuous. 
Apex  of  disc  measured  by  C  D.  Refraction  about  2  D.,  so  that 
disc  swelling  amounted  to  4  D.  Left  same  appearances.  Disc, 
measured  by  6  D.    Retinal  level  by  2  D.    Swelling  =  4  D. 

'' Subsequent  observation  showed  slightly  greater  swelling 
in  right  than  left  disc;  no  evidence  of  choroidal  change  or  of 
peripheral  retinitis.  Fields  shows  slight  periplieral  contraction 
of  right  with  inversion  of  red  and  green  fields.  On  left  form 
field  full,  blue  field  contracted,  green  field  larger  than  red  but 
interlaces  in  three  meridians.  Conspicuous  clinical  feature  of 
the  case  is  the  momentary  obscuration  of  vision  followed  by 
rapid  restoration.  Patient  closely  followed,  vision  never  got 
lower  than  right  6/8+.     Left  6/5. 

''March  6th:  The  day  following  opening  of  right  post- 
ethmoidal-sphenoidal  cells,  vision  was  raised  from  6/6  to  6/4 
with  the  right  eye. 

"March  12th:  Day  following  operation  on  left  post-eth- 
moidal-sphenoidal  cells,  vision  was  raised  from  6/4  missing  2 
letters  to  6/4  missing  1  letter. 

"April  10th:  Distinct  recession  of  papillary  swelling; 
right  apex  measured  by  41^  D.,  and  left  apex  by  5^  0.  From 
this  time  neuritis  slowly  subsided. 

"November  6,  1914:  Both  discs  were  at  level  of  retina 
and  fairly  well  tinted. 

"Last  observation  July  12th,  1915;  right  and  left  vision 
6/4;  fields  full.  Both  discs  a  little  pale  but  showing  no  other 
evidence  of  antecedent  inflammation." 

Clinical  course :  Post-ethmoidal-sphenoidal  operation,  right 
side,  March  5,  1914.  Left  side,  March  11,  1914.  Eyes  began 
to  improve  almost  at  once  (see  above.  Dr.  Green's  report).    Six 


CASE    HISTORIES  223 

days  later  lower-lialf  headache  (maxillary  and  Vidian  neural- 
gia) began  to  lessen  and  later  ceased.  Jnly  27,  1914,  a  coryza 
made  head  ache  and  some  increased  disc  SAvelling  and  a  paresis 
of  the  facial  nerve  of  right  side.  This  diagnosis  Avas  contirmed 
by  Drs.  Hempelmann  and  M.  A.  Bliss.  This  condition  lasted  7 
days.  August  15,  1914,  began  another  exacerbation  of  the  local 
inflammation  and  Avas  folloAved  by  A^omiting  for  36  hours  Avitli 
some  headache.  August  27,  1914,  appeared  a  paresis  of  the  left 
facial  nerA^e  Avith  a  right-sided  exophthalmos  (Drs.  Green,  Hem- 
pelmann and  Bliss).  Intrasphenoidal  observation  with  Holmes' 
pharyngoscope  during  these  periods  contirmed  the  diagnosis  of 
acute  exacerbation.  By  the  same  means  it  Avas  knoAvn  to  have 
been  absent  before  and  proved  to  be  absent  later  (after  14 
days)  Avlien  recoA^er}^  of  eye,  facial  paresis,  and  exophthalmos 
was  established. 

Last  observation  by  me  April  10, 1915,  confirmed  Dr.  Green's 
of  November  6,  1914,  of  recoA^'ery.  The  clinical  changes  in  the 
sphenoid  district  had  subsided  to  such  a  degree  as  to  leave  it 
normal  clinically.  In  the  first  eighteen  months  he  has  had  for  the 
first  time  tAvo  epileptic  seizures. 

Dr.  Wright  has  reported  this  case  in  full  in  the  introduction. 

This  case  is  in  marked  contrast  to  E.  H.  G.,  page  203,  the 
pathological  changes  in  Avliich  are  also  giA^en  in  detail  by  Dr. 
Wright  in  the  introduction.  The  hyperplastic  process  in  E.  H.  G. 
Av^as  the  most  marked  of  all  the  cases.  Surgically  the  bone  Avas 
heaA^ier  and  harder  than  any  of  these  cases  Avith  one  or  tAVO 
exceptions  Avhich  Avere  equally  hard.  The  result  for  E.  H.  G. 
Avas  a  failure  as  far  as  his  eye  Avent.  The  process  in  E.  D. 
shoAved  a  rarefying  state  of  the  same  lesion.  The  result  for 
E.  D.  Avas  all  that  could  have  been  desired.  What  the  significance 
of  the  recently  deA^eloped  epilepsy  may  be  cannot  at  present  be 
stated. 

L.  W.,  25  years  old,  consulted  me  Jan.  16,  1913,  because  of 
great  headache,  loAver  half,  Avhich  had  endured  for  six  years. 
She  had  been  in  the  charge  of  various  physicians,  some  of  them 
rhinologists.  Some  one  had  opened  the  capsule  of  the  ethmoid 
on  the  left  side.  Examination  revealed  a  high-grade  hyper- 
plastic post-ethmoiditis ;  and  it  Avas  my  judgment  to  open  the 


224  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

post-etlimoidal-spheiioidal  district.  The  left  pupil  was  fre- 
quently larger  than  the  right.  The  right  and  left  post-ethmoidal- 
sphenoidal  operations  were  done  in  October  and  December  of 
1913. 

She  was  somewhat  slow  in  getting  any  results  from  the  sur- 
gery. The  bone  was  intensely  hard  and  with  great  difficulty 
cut  through  by  means  of  the  little  angle  knife  described  in  the 
foregoing  text.  I  succeeded  very  satisfactorily,  hoAvever,  in 
opening  the  sphenoidal  cell  proper. 

Because  of  the  delay  in  receiving  benefit  from  the  surgery, 
I  decided  to  investigate  the  sub-division  of  the  sinus  and  placed 
a  probe  in  its  uppermost  limits  for  an  x-ray  picture.  It  showed 
a  small  cell  above  the  one  opened.  I  then  attempted  to  open 
this  cell.  I  succeeded  in  entering,  through  very  hard  bone,  a 
small  cell  in  the  upper  outer  part  of  the  sphenoidal  face,  the 
opening  remaining. 

Since  that  time  she  has  ])een  frequently  for  long  stretches, 
six  to  ten  weeks,  free  from  pain. 

The  case  for  the  past  year  has  been  greatly  complicated  by 
a  bad  dysmenorrhoea.  When  this  patient  menstruates,  almost 
every  time  it  is  a  major  illness,  and  she  does  not  recover  in 
the  three  weeks'  interval  from  what  she  loses  during  the  one 
week  in  which  she  menstruates. 

In  this  way  she  has  slowly  lost  ground,  and  much  of  the 
time  suffers  intense  headache,  particularly  during  the  men- 
strual stage. 

In  an  effort  to  exclude  all  possible  influences  that  might 
bear  upon  this  unfortunate  case,  she  was  put  into  the  Barnes 
Hospital,  and  an  entire  gynecological  and  neurological  investi- 
gation carried  out  by  Doctors  Schwab,  Sachs,  and  Taussig,  and 
I'omplete  x-ray  investigation  for  everything  possible,  and  all 
the  laboratory  tests  that  are  at  the  present  time  deemed  to  be 
serviceal)le  in  the  elucidation  of  such  a  case,  were  employed. 

In  the  course  of  this  investigation.  Dr.  Meyer  Wiener  discov- 
ered that  she  had  a  slight  neuritis  of  the  right  optic  nerve.  He 
found  the  lower  inner  margin  of  the  right  disc  sliglitly  blurred ; 
the  veins  normal  in  color,  size  and  contour;  arteries  slightly 
more  tortuous  than  usual;  refraction  in  +1  diopter;  fields  of 


CASE    HISTORIES  225 

vision  show  no  abnormality;  the  blind  spots,  however,  not  out- 
lined. 

This  ease  to  me  is  intensely  interesting,  not  only  showing 
the  influence  of  menstrual  disturbances,  Avhich  have  intensified 
the  headache  very  much,  but,  in  the  course  of  the  routine  in- 
vestigation is  discovered  an  optic  neuritis  of  such  Ioav  grade  that 
it  had  not  announced  itself  ophthalmologically.  It  raises  tlie 
c{uestion  in  one's  mind  as  to  how  often  these  patients  suffer 
more  or  less  eye  disturbance.  I  mean  by  that  optic  nerve  or 
choroidal  disturbances  that  are  not  recognized  clinically.  They 
do  not  attract  the  patient's  attention,  and  they  are  therefore 
not  submitted  to  the  ophthalmologist.  The  attacks  of  transitory 
blindness  which  I  liave  recorded  have  so  often  seemed,  for  the 
most  part,  to  have  been  a  manifestation — probably  a  toxemia 
of  the  nerve  by  juxtaposition  of  the  sinuses,  Avhicli  lias  not  regis- 
tered a  visible  lesion. 

Intrasphenoidal  Observations  of  Interest 

A.  B.,  strong,  healthy  man,  30  years  old,  referred  by  Dr. 
A.  E.  Ewing,  January  15,  1915,  for  a  severe  serous  iritis  R., 
with  blood  vitreous.  Vision,  3/120  R.  eye,  L.  normal.  My  diag- 
nosis :  Sphenoid  suppuration,  R.  It  a^Dpeared  subacute  with  no 
definite  hyperplastic  features.  No  headache.  He  did  not  ac- 
cept the  proposed  surgical  procedure.  February  7,  1915,  he  de- 
veloped an  acute  coryza.  February  10,  1915,  he  returned.  V. 
counts  fingers  at  1  foot,  recognizes  the  movement  of  liand  at  3 
feet.  The  anterior  chamber  is  now  full  of  blood.  February  11, 
1915,  i^ost-ethmoidal-sphenoidal  operation.  The  cavity  of  the 
sphenoid  was  found  to  ))e  large  and  lent  itself  to  very  satisfac- 
tory surgical  manipulation.  The  anterior  wall  was  readily  cut 
out  with  sufficient  general  shock  to  lower  the  blood-pressure  so 
that  there  was  almost  no  bleeding  and  withal  no  syncope.  He 
was  then,  as  it  were,  a  perfect  manikin.  The  Holmes  pharyngo- 
scope was  at  once  introduced  into  the  cavity  of  the  sphenoid 
which  showed  on  that  part  making  the  inner  aspect  of  the  optic 
canal,  a  patch  a  little  less  than  1  cm.  in  diameter  which  at  this 
center  was  a  bluish  gray  and  thickened  and  marked  by  blood- 
vessels, centered  there  from  all  directions.  It  was  one  of  those 
vascular  communications  described  bv  Shambaugh  and  others 


226  HEADACHES    AXD    EYE    DISORDERS    OF    :NASAL    ORIGIN 

between  the  membrane  of  the  canal.  From  its  center  the  thick- 
ening began  to  recede  and  the  color  to  approach  normal.  The 
remaining  membrane  showed  somewhat  of  a  bluish  addition  to 
its  color.  The  cavity  held  a  scant  secretion  apparently  opales- 
cent. In  8  days  the  patch  and  blood-vessels  had  vanished,  and 
the  eye  had  begun  to  improve  from  what  Avas  a  progressively 
desperate  state  according  to  Dr.  Emng — 5  mos.  V.  3/75. 

Dr.  Wright's  report  of  the  changes  in  the  sphenoidal  wall. 
Hyperplasia  M.  M.  erectile  tissue.  Enormously  dilated.  Sinus 
gorged  with  blood.  No  bone  involvement,  slight  periostitis. 
Sphenoidal  wall.  This  is  an  exceptional  chronic  edematous  in- 
flammation of  the  mucous  membrane,  exceptional  in  this :  (1)  the 
great  development  and  dilation  of  the  erectile  venous  sinuses  in 
this  situation.  (2)  The  thickening  of  the  media  of  the  coats 
of  the  radicle  arterioles.  (3)  The  very  moderate  amount  of  bone 
affection,  considering  the  excessive  (for  this  situation)  amount 
of  periosteal  thickening,  but  the  bone  itself  is  not  materially  in- 
volved. 

Epilogue :  Apparently  we  have  here  an  inflammatory  proc- 
ess Avhicli  has  extended  along  the  nerve  sheath,  if  we  are  to  pre- 
serve the  character  of  the  inflammation  the  same  in  the  sinus  as 
in  the  middle  turbinate,  before  marked  change  is  produced  in 
the  underlying  bone  locally  in  the  nose.  Mucous  membrane 
shows  extensive  degeneration  with  evidence  of  primary  Avascular 
change. 

Miss  A.  K.,  40  years  old,  normal,  referred  December  13, 
1913,  by  Di-.  M.  li.  Post,  Jr.,  for  choroiditis,  L.  V.  20/94  L.  My 
diagnosis :  Post-ethmo-sphenoiditis  AA^ith  edema  and  pus,  L.  De- 
cember 9,  1913,  post-ethmoidal-sphenoidal  operation.  At  the 
time  of  opening  the  cells  Avere  found  by  the  pharyngoscope  to 
contain  poNps.  Vision  has  risen  to  20/24.  A  scotoma  remains. 
She  sees  a  black  spot  in  the  upper  outer  field  of  that  (L)  eye. 
Since  the  healing  Avas  complete  and  Aasion  largely  restored  I 
have  seen  her  in  4  coryzas.  She  lost  vision  in  3  of  the  attacks 
and  shoAved  by  the  pharyngoscope  a  patch  of  acute  inflammation 
twice  in  the  sphenoid  at  the  site  of  the  optic  canal  and  once 
in  the  post-ethinoid  Avith  polyps  at  this  site.  In  one  coryza  the 
patch  was  in  the  loAver  and  outer  area  of  the  sphenoid  and  ac- 


CASE    HISTORIES  227 

companied  by  severe  lower-half  anterior  headache  but  no  loss  of 
.  vision.    Dr.  AVright  has  not  examined  the  bone  from  this  case. 

I  have  a  similar  case  referred  by  Dr.  AV.  A.  Shoemaker 
with  choroiditis,  recurrent  and  great  headache  relieved  by 
operation  with  betterment  of  vision.  The  bone  in  this  case 
has  not  yet  been  examined  by  Dr.  Wright. 

In  two  other  cases  of  diagnosis  of  non-snppnrative  liyj)er- 
plastic  sphenoiditis  with  headache  (lower  half),  there  came  at 
the  time  of  greatest  intensity  of  the  pain  in  one  case  a  loss 
of  consciousness  lasting  usually  from  5  to  10  min.,  and  in  the 
other  the  sight  of  innumerable  men  approaching  fi-om  the  right 
and  countless  rats  approaching  on  the  floor  from  the  left.  In 
both  cases  the  x^ain  and  other  features  of  the  case  were  stopped 
by  the  operation  to  return  at  the  time  of  a  severe  coryza  and 
again  disappear. 

Tic  Douloureux 

W.  B.,  45  years  old,  consulted  me  January  20,  1914,  because 
of  neuralgia,  described  as  lower-half  headache. 

Examination  of  the  nose  revealed  an  acute  post-ethmoidal 
sphenoiditis,  more  marked  at  the  site  of  the  sphenopalatine 
foramen.    Cocainization  of  the  ganglion  stopped  the  pain. 

He  was  delighted,  as  it  aborted  the  attack  whicli  usually 
lasted  ten  days. 

He  had  suffered  such  headache  all  his  life  at  intervals.  It 
occurred  probably  at  the  recurrence  of  coryzas.  He  has  a  Ioav 
grade  hyperplastic  post-ethmoidal  sphenoiditis.  With  each  of 
these  attacks  is  developed  a  severe  tic  douloureux  of  the  max- 
illary and  Vidian,  establishing  a  lower-lia.lf  tic.  Cocainization 
of  the  ganglion  relieved  the  tic.  It  recurred  after  the  cocaine 
Avore  away,  but  usually  very  little. 

On  another  occasion.  Dr.  B.  came  to  me  because  of  a  tic  in 
the  mandibular  nerve. 

As  far  as  the  ordinary  nose  is  concerned,  the  mandibular 
nerve  is  not  related  to  the  sphenoidal  sinus,  or  the  nasal  gan- 
glion. Cocainization  of  the  nasal  ganglion  here  did  not  in  any 
Avay  influence  the  third  division.    The  experiment  was  tried,  and 


228  HEADACHES    AXD    EYE    DISORDERS    OF    XASAL    ORIGI^- 

failure  was  absolute.    The  next  day  he  discovered  a  tooth  was 
responsible  for  the  tie. 

It  is  interesting  to  note  that  in  this  case  he  developed  a 
tic  always,  whether  he  developed  the  constant  headache  or  not. 
Apparently  different  lesions  of  tlie  peripheral  distribution  of 
the  trigeminus  produced  the  tic. 

Miss  J.  S.,  50  years  old,  was  referred  to  me  Jan.  10,  1913, 
by  Dr.  T.  H.  Halstead  for  a  right  tic  douloureux  of  the  max- 
illary and  mandibular  nerves.  Peripheral  injections  had  not 
been  satisfactory.  She  had  a  right  suppurating  sphenoid.  The 
post-ethmoidal-sphenoidal  operation  was  done  Jan.  15,  1913. 
The  result  was  relief  from  the  tic  until  1917  when  it  had  re- 
curred and  a  semilunar  ganglionectomy  was  done.  This  case 
seemed  to  me  to  originate  from  the  sphenoid.  It  shows  the 
progress  of  the  ''tic"  when  once  well  started. 

G.  H.,  a  normal. man,  50  years  old,  referred  to  me  by  Dr. 
W.  E.  P^ischell,  1901.  He  had  a  chronic  Eustachian  tube  ol)struc- 
tion  for  which  I  did  a  posterior  cautery  operation'^^''  in  1902  with 
complete  relief.  In  1910  he  suffered  from  a  severe  right  post- 
ethmoidal-sphenoidal  suppuration  witli  lower-half  great  head- 
ache. It  proved  to  be  obstinate  and  Feb.  26,  1910,  the  post- 
ethmoidal-sphenoidal  operation  (right)  was  done.  It  relieved 
the  headache.  From  time  to  time  he  has  had  coryzas  to  make 
slight  transitory  headache,  to  cease  with  recovery  from  the 
coryza.  May  7, 1918,  he  again  developed  a  severe  coryza  accom- 
panied by  an  unusual  phenomenon;  to  wit,  a  violent  stabbing 
pain  Avliich  pierced  his  right  eye  during  sleep.  It  awakened  him 
on  two  mornings  at  3  a.  m.  and  continued  through  the  days 
in  slight  degree  despite  acetphenetidin  gr.  v  and  codeine  gr.  14 
every  3  hours.  Examination  showed  acute  inflanunation  of  the 
right  post-ethmoidal-sphenoidal  district.  Cocainization  of  the 
nasal  ganglion  stopped  the  eye  pain. 

J.  S.  consulted  me  Oct.  20,  1914,  because  of  great  pain  in 
the  lower  half  left  side  of  the  head,  which  he  had  suffered  as 
far  back  as  his  memory  reached. 

Examination  showed  a  perfectly  well-marked  inflammatory 


CASE    HISTORIES  229 

patch  on  the  left  sphenopalatine  foramen.  I  found  that  cocaine 
stopped  the  pain. 

It  Avas  therefore  decided  to  inject  the  ganglion,  which  was 
done  once  only.    It  stopped  the  pain.    It  has  not  Tetnrned. 

I  feel  special  emphasis  should  be  laid  upon  the  character  of 
it.  It  was  more  or  less  a  constant  pain,  but  mixed  in  with  it  was 
a  perfectly  clearly  defined  tic  Avhich  came  as  a  stabbing  to  the 
lower  half  of  the  head,  neck  and  shoulder  at  intervals  not  more 
than  a  few  hours  apart.  This  Avas  particularly  marked  in  the 
posterior  distribution  of  the  pain,  the  anterior  distribution 
being  for  the  most  part  free  of  the  tic. 

To  my  mind,  this  case  is  particularly  interesting  as  an 
exposition  of  tic  of  the  Vidian,  i.  e.,  relative  to  the  Vidian  nerve 
taking  on  the  sharp  recurrent  stabbing  attacks  that  character- 
ize many  cases  of  trigeminal  neuralgia. 

I  have,  in  all,  ten  cases  in  Avhich  the  posterior  pain  was  of 
this  type,  Avhere  the  posterior  disturbance  Avas  a  tic  pure  and 
simple,  Avithout  the  general  course  of  more  or  less  constant  pain. 

The  case  Avas  sent  to  me  l)y  Doctor  Sidney  I.  ScliAvab. 

Sphenoiditis  and  Tic  Douloureux 

Miss  J.  8.  consulted  me  Feb.  10,  1914,  complaining  of  a 
seA^ere  tic  of  the  second  and  third  divisions  of  the  right  side. 
Examination  reA^ealed  a  high  grade  suppurative  sphenoiditis. 
The  tic  had  lasted  several  years  and  had  had  peripheral  injec- 
tions Avith  110  result.  The  sphenoid  Avas  opened  on  Feb.  15,  1914, 
and  the  case  remained  free'  of  tic  for  three  years.  In  a  letter 
recently  she  announced  tliat  the  tic  returned  and  all  efforts  to 
relieve  it  failed,  till  finally  a  semilunar  ganglionectomy  Avas 
done.  The  case  is  of  interest  to  me  shoAving  a  tic  Avhich  seemed 
to  be  clearly  of  sphenoidal  inflammatory  origin.  It  is  also  in- 
teresting to  note  the  duration  of  the  relief  that  had  not  been 
obtained  by  any  other  means.  It  is  also  interesting  to  show  that 
such  cases  once  effected  may  go  on  until  a  ganglionectomy  is 
required. 

Iritis 

L.  R.,  aged  30  years,  sent  to  me  by  Doctor  A.  E.  EAving, 
Jan.  10,  1918,  because  of  an  intractable  iritis.  Doctor  Ewing 
had  giA^en  treatment  Avliich  left  much  to  lie  desired  in  the  prog- 


230  HEADACHES    AXD    EYE    DISOEDEES    OF    Is^ASAL    ORIGUST 

ress  of  the  case  for  the  co]itrol  of  pain.  He,  therefore,  submitted 
it  to  me  for  a  nasal  examination. 

A  clearly  mai'ked  post-ethmoiditis  was  found  upon  that 
side  (rio-ht).  The  lesion  was  soft,  velvety,  swelling-  of  the  pos- 
terior tip  of  the  middle  turbinate,  without  secretion. 

Full  eocainization  of  the  ganglion  relieved  all  the  pain  of 
his  eye,  and  A\'as  followed  by  an  immediate  turn  for  improve- 
ment, which  continued  from  then  on.  The  nasal  ganglion  was 
cocainized  slightly  after  that  for  ten  days,  when  the  condition 
in  his  eye  had  improved  so  much  that  it  seemed  unnecessary 
to  pursue  the  anaesthesia.  The  case  was  treated  for  another  ten 
days  by  carbolized  oil.  His  e^^e  recovered,  and  he  was  dismissed. 
The  lesion  within  his  nose,  in  the  meantime,  appeared  to  sub- 
side totally. 

Many  times  I  have  seen  such  cases  as  this,  always  of  great 
interest,  and  impossible  of  explanation  at  present. 

Miss  J.  B.,  24  years  old,  consulted  me  June  10,  1914.-  She 
had  been  my  patient  five  years  before  for  some  trifling  acute 
trouble  of  short  duration.  Present  history:  For  three  years 
has  been  subject  to  attacks  of  iritis,  with  photophobia,  redness 
and  pain  not  only  in  eyes  but  extending  to  occiput,  which  would 
get  nearly  well  and  then  continue  in  low  grade  for  months  to  be 
rekindled  from  causes  unknown.  The  condition  is  much  better 
than  its  worst,  but  far  from  Avell.  The  sphenopalatine  foramen 
membrane  of  the  left  side  is  inflamed  and  thickened.  The  iritis 
is  always  on  left  side.  Cocaine  applied  to  foramen  stopped  the 
discomfort  in  eye  and  occiput  in  five  minutes.  It  did  not  return. 
Silver  nitrate  and  acetic  acid  applications  were  made  to  com- 
plete the  treatment.  The  redness,  pain  and  photophobia  of 
the  iritis  did  not  return  after  the  cocaine  application.  Two 
weeks  later  the  eve  was  declared  bv  her  ophthalmologist  to  be 
well. 

Photophobia 

R.  A.  G.,  aged  40  years,  school  teacher,  normal  man,  was 
sent  to  me  by  Doctor  A.  E.  Ewing,  because  of  photophobia  that 
was  not  explained  by  any  ophthalmological  condition. 

Examination  revealed  a  well-marked  hyperplastic  post-eth- 
moidal  sphenoiditis. 


CASE    HISTORIES  231 

Effort  to  control  the  photophobia  from  the  nasal  ganglion 
was  not  successful.  The  treatment  by  forcible  injection  of  car- 
bolized  oil  into  the  sphenoidal  district  was  rapidly  followed  by 
cessation  of  the  photophobia.  The  case  has  stood  a  year  now 
in  comfort.  It  is  of  interest  as  one  of  the  more  unusual  ocular 
manifestations,  apparently  j^roduced  by  an  inflammatory  lesion 
in  the  post-ethmoidal-spherioidal  district. 

Paresthesia  of  Upper  Extremity  from  Injection 

Miss  B.  0.,  aged  35  years,  slender,  frail,  neurotic  girl.  Was- 
sermann  negative;  no  organic  lesions  discoverable.  She  was 
my  patient  for  iifteen  years,  sometimes  for  acute  sore  throat, 
sometimes  for  nasal  obstruction ;  latterly  for  neuralgia  of  lower- 
half  of  head,  of  neck  and  shoulder,  and  shoulder  blade  and  of 
arm. 

Cocainization  of  the  ganglion  helped  the  pain  in  her  head 
and  neck ;  but  made  a  very  unpleasant  tingling  sensation  in  her 
arm. 

The  pathological  lesion  is  a  post-ethmoidal  sphenoiditis, 
not  specially  hyperplastic,  but  rather  high  grade,  manifested 
Ijy  a  great  redness,  with  only  a  small  degree  of  swelling  and 
little  serous  secretion. 

The  injection  of  the  ganglion  has  been  followed  by  a  fair 
degree  of  relief  from  pain.  The  inflammatory  post-nasal  con- 
dition is  better.    The  tingling  in  her  arm  remains. 

Effort  has  been  made  by  Doctor  Walter  Baumgarten  to 
help  the  condition  by  diet  free  from  animal  protein. 

It  did  not  accomplish  the  result.  Internal  medicine  treat- 
ment in  general  did  not  relieve  the  nasal  condition. 

The  case  is  of  interest  because  of  the  tingling  sensation  in 
the  arm.  I  have  repeatedly  heard  such  paresthesias  described 
as  "itching"  or  "burning."  This,  however,  is  the  only  in- 
stance when  it  was  produced  by  the  injection. 

Mrs.  N.  H.,  aged  45  years,  consulted  me  April  1,  1900,  be- 
cause of  headache  and  great  discomfort  in  the  use  of  her  eyes. 
The  middle  meatus  of  each  side  was  found  to  be  closed.  The 
anterior  half  of  the  middle  turbinate  was  for  that  reason  re- 


232  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

moved.  This  gave  considerable  comfort  in  the  daily  use  of  the 
eyes;  but  a  recurrent  headache  of  great  severity  continued  at 
intervals.     This  arose  from  hyperplastic  post-ethmoiditis. 

The  patient  was  not  seen  again  for  a  number  of  years,  when 
she  stated  that  she  thought  that  she  was  getting  better.  Ex- 
amination last  year  revealed  the  fact  that  the  post-ethmoiditis 
had  involuted  to  such  an  extent  as  to  appear  gone  altogether. 
It  appeared  normal.  She  made  the  statement  that  she  was  now 
practically  free  of  the  intense  headaches  that  had  recurred  at 
intervals  of  two  or  three  weeks. 

To  my  mind,  this  case  is  a  combination  of  the  vacuum  fron- 
tal headache,  which  was  relieved,  and  considerable  benefit  gained, 
by  opening  the  frontal  inlet,  and  of  a  post-ethmoiditis  hyper- 
plastic which,  as  life  went  on,  that  is,  passed  the  menopause, 
slowly  involuted. 

At  the  present  time  she  is  free  of  such  headaches. 

This  patient  had  been  examined  by  all  kinds  of  intelligent 
medical  men,  and  all  kinds  of  treatment  had  been  instituted  and 
pursued.  The  case  was  classed  by  neurologists  as  a  vulgar  me- 
grim. To  my  mind,  it  was  i-elieved  in  later  life  by  a  rarefying 
ostitis,  in  the  post-ethmoidal-sphenoidal  district. 

Orbital  Hemorrhage 

H.  L.,  aged  19  years,  consulted  me  Dec.  18,  191-4,  sent  by 
Doctor  M.  H.  Post,  and  complaining  that  he  very  frequently  had 
a  hemorrhage  into  the  eye  socket. 

Examination  revealed  a  bilateral  sphenoiditis,  Avhich  other- 
wise was  without  symptoms. 

Observation  of  tlie  case  revealed  that  a  coryza  was  usually 
accompanied  by  a  small  hemorrhage  into  the  orbit,  first  one 
side,  then  the  other.  I  know^  no  explanation  to  offer.  I  merely 
record  the  facts. 

Tabes 

Mrs.  C,  aged  40  years,  sent  to  me  by  Doctor  A.  E.  Ewing, 
June  3,  1913,  because  of  failing  vision.  She  had  a  bilateral 
sphenoiditis. 

Investigation  at  that  time  showed  a  well-defined  tabes,  but 


CASE    HISTORIES  233 

it  Avas  determined  to  open  the  sphenoid  cells,  despite  this  fact. 
No  benefit  was  derived  from  this  operative  procedure. 

I  have  another  case  exactly  similar  in  every  respect,  also 
referred  by  Dr.  Ewing.  A  man  70  years  of  age,  who  was  not 
operated,  l)ecause  of  his  advanced  years,  to  whom  treatment  was 
given; — forcible  filling  of  the  olfactory  fissure  with  carbolized 
oil.  In  three  months  his  vision  improved  markedly  despite  the 
fact  that  he  had  a  well-defined  tabes.  These  cases  show  the  dif- 
ficulty in  separating  the  causes  of  eye  lesions  in  the  presence  of 
sphenoiditis. 

Ethmoidal  Pain  and  Peripheral  Nerve-trunk  Injection 

S.  M.  J.,  aged  25  years,  was  sent  to  me  by  Doctor  Yilray 
Blair  on  Mar.  1,  1915.  She  suffered  very  great  headache.  Doc- 
tor Blair  in  the  effort  to  alleviate  the  pain  had  injected  ^ith 
alcohol  the  second  and  third  divisions  of  the  fifth  of  that  side, 
but  although  a  i)erfect  peripheral  anaesthesia  was  secured,  the 
pain  continued  unchanged.  Nasal  examination  showed  an  eth- 
moiditis  anterior  and  posterior;  operation  for  which  was  suc- 
cessful, relieving  the  pain.  This  case  is  of  interest  showing  how 
total  anaesthesia  of  the  peripheral  nerve  distribution  may  not 
carry  with  it  relief  from  the  pain  produced  by  sup]Durative 
sinuses. 

Change  to  Sympathetic  Type  With  Anaphrodisiac  Effects 

S.  Y.,  50  years  old,  normal  man,  had  throughout  his  life  what 
I  should  term  "ordinary"  coryzas  beginning  with  sneezing  last- 
ing three  or  four  hours  and  watery  discharge  of  usually  one 
day,  after  which,  nasal  obstruction  for  two  or  three  days,  fol- 
lowed by  thick  mucopui'ulent  secretion.  Very  seldom,  a  few 
times  in  his  life,  he  had  slight  headache  of  a  day  or  two  dura- 
tion. In  1912  he  developed  a  type  of  coryza  manifest  by  Avatery 
secretion  and  sneezing  only.  The  obstruction  and  suppuration 
AA'ere  omitted.  During  that  year  he  had  four  such  attacks,  all 
much  milder  than  his  previous  attacks.  In  1913  he  liad  added 
to  this  a  sharp  complete  nasal  ganglion  neuralgia  Avliich  har- 
assed him  more  or  less  for  two  months  and  a  paroxysmal  morn- 
ing sneezing  lasted  two  months  longer.  Since  1913  he  has  had 
six  such  attacks,  each  with  more  or  less  eye  discomfort  added 


234  HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIN 

to  the  profuse  watery  secretion  and  great  sneezing  with  pain 
in  and  around  right  eye ;  earache  and  stuffiness,  pain  in  mastoid, 
occiput,  neck,  shoulder  blade,  shoulder,  arm  and  forearm.  In 
this  time  he  has  not  had  the  mucopurulent  discharge  of  former 
times.  The  sphenopalatine  foramen  membrane  is  markedly  in- 
flamed, and  once  he  had  a  post-ethmoidal-sphenoidal  inflam- 
mation well  marked. 

This  case  shows  Iioav  the  sympathetic  elements  once  added 
to  the  clinical  factors  have  recurred  with  each  coryza  over  a 
period  of  six  years.  He  also  reports  marked  anax)hrodisiac 
effects  at  the  time  of  the  attacks. 

Vertigo 

Mrs.  IT.  C.  M.,  35  years  old,  Joplin,  Mo.,  consulted  me  De- 
cember 15,  1917,  complaining  of  great  lower-half  headaches, 
right  and  left,  accompanied  by  dizziness — "the  objects  went 
around  her" — of  such  severity  that  she  was  able  to  walk  only 
with  difficulty.  She  had  suffered  8  years  from  these  conditions. 
Examination  revealed  a  Avell-marked  post-ethmoidal  sphenoid- 
itis,  Avith  considerable  acute  element  mixed  with  it.  In  the  ef- 
fort to  localize  the  point  from  which  the  pain  proceeded,  co- 
cainization  of  the  ganglion  w"as  followed  by  cessation  of  the 
headache,  Avith  almost  instantaneous  relief  of  the  dizziness. 
After  six  hours  the  headache  returned  to  some  extent ;  but  the 
dizziness  was  almost  absent. 

OAA'ing  to  this  patient  liAdng  at  a  distance,  further  observa- 
tion has  so  far  been  impossible. 

This  patient  had  been  carefully  investigated  in  eveiy  de- 
partment of  a  general  examination. 

This  case  is  of  interest  shoAving  dizziness,  of  rotatory  type 
stopped  by  cocainization  of  the  nasal  ganglion. 

Trig^eminal  Hypalgesia,  Paresthesia,  Hypesthesia,  Pupil 
Dilated — Sphenoiditis 

Miss  H.  M.,  35  years  old,  referred  by  Dr.  F.  R.  Fry  and 
Dr.  A.  E.  EAving,  March  10,  1914.  She  had  suffered  A^olent 
headaches  as  long  as  slie  could  remember,  recurrent  at  irreg- 
ular intervals    (type   of  vulgar  megrim)   but  getting  A\'orse. 


CASE    HISTORIES  235 

My  diagnosis:  Hyperplastic  sphenoiditis  (non-siippiirative  R. 
&  L.).  Dr.  Fry's  report:  She  has  a  parasthesia  hypesthesia 
and  hypalg-esia  in  distribution  of  fifth  nerves  which  I  feel  certain 
is  of  organic  genesis.  The  different  kinds  of  impairment  are 
co-extensive  at  present.  The  left  pupil  is  a  little  larger.  They 
react  fairly  well.  Dr.  Swing's  report  of  eye  conditions  March 
5,  1914,  vision  20/15  li.  and  L.  Slight  blurring  of  disc  margins 
pathological  (?).  Slight  paresis  of  right  side  of  face.  Advised 
to  consult  Dr.  Fry.  Fost-ethmoidal-sphenoidal  operation  of 
left  side  June  5,  1914 ;  of  right  side  Fel^ruray  11,  1915.  On  June 
1,  1915,  Dr.  Fry  reports  a  return  to  normal  of  above  stated 
changes  and  Dr.  Ewing  reports  disc  normal,  possibly  a  slight 
blurring  still  of  left  disc  margin.  A  note  dated  July  6,  1914, 
at  the  time  of  a  coryza  shows  the  left  disc  to  have  been  swollen, 
2  diopters.    Tliis  lasted  three  Aveeks. 

Dr.  "Wright's  repoi't:  Sphenoidal  wall  shows  a  marked 
chronic  inflammation  with  involvement  of  periosteum ;  and  bone 
to  a  moderate  extent.  Middle  turbinate':  There  is  a  chronic 
fibrous  hyperplasia  of  the  soft  parts  involving  the  walls  of  the 
arterioles.  The  l^one  shows  no  marked  changes.  June  1,  1915, 
free  of  pain,  except  slight  occasional  occipital  headache.  She 
has  at  times  a  low  grade  tingling  sensation  of  right  side  of  face. 

Vernal  Hay  Fever 

Mrs.  J.  S.,  4G  years  old,  my  patient  since  1898,  for  many 
years  has  had  vernal  hay  fever  of  full  severity  accompanied  by 
red  and  swollen  nose  and  tearing  eyes.  Cocainization  of  the 
nasal  ganglion  a  few  times  in  the  course  of  the  spring  months 
is  sufficient  to  carry  her  through  the  attack  with  only  a  very 
slight  morning  sneezing  on  irregular  days.  Her  external  nose, 
however,  becomes  red  and  swollen  at  any  time  of  the  year  from 
the  slightest  irritation  of  the  internal  nose  and  remains  red 
without  recognizable  cause  much  of  the  time.  Silver  nitrate 
applied  to  the  sphenopalatine  membrane  two  or  three  times  a 
week  out  of  liay  fever  season  brings  the  appearance  to  normal. 
It  then  remains  so  for  long  periods,  to  be  excited  again  from 
within  the  nose.  In  the  hay  fever  season  she  has  dyspnea  with 
dry  rales  equally  distributed  R.  and  L.  Cocainization  of  the 
nasal  ganglion  of  one  side  will  stop  the  rales  on  that  side.    All 


236  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

treatment  kll()^vll  to  me  prior  to  the  spriiio-  of  1914  was  in  vain. 
At  that  time  1  began  the  eocainization  of  the  nasal  ganglion  and 
the  treatment  of  tlie  rosacea  followed  that. 

Acute  Blindness 

Mrs.  J.  D.,  38  3^ears  of  age,  referred  by  Dr.  W.  E.  Shahan, 
Jnne  21, 1914.  Diagnosis:  Hyperplastic  sphenoiditis  with  acute 
suppuration.  Dr.  Shahan 's  report:  June  12  last  was  seized 
with  violent  headache  left  side,  wliich  lasted  live  days  when  it 
began  to  subside  and  the  vision  of  left  eye  began  to  fail.  Now 
counts  fingers  at  one  foot.  Lower  and  central  field  absent. 
Disc  appears  slightly  swollen  and  slightly  hyperemic  at  upper 
margin.    Right  eye  normal. 

June  24,  1914.  Post-ethmoidal-sphenoidal  operation.  Dr. 
Wright's  report:  Sphenoidal  wall — marked  hyperplasia  of  the 
bone  and  the  periosteum  is  markedly  infiltrated  with  products 
of  inflammation  in  some  parts.  Some  areas  of  the  mucous 
meml)rane  show  marked  adenomatous  h^q^ertrophy  with  sub- 
epithelial edema.  The  changes  in  the  soft  parts  are  of  a 
chronic  nature,  probably  a  very  old  process  in  the  mucous  mem- 
brane. 

Middle  turbinate — the  surface  epithelium  is  papillary  and 
thickened.  There  is  a  very  great  amount  of  edematous  infiltra- 
tion of  tlie  sul)-epithelial  connective  tissue.  The  lymph  chan- 
nels are  enormously  dilated  in  it.  The  blood-vessels  are  not 
markedly  involved.  The  mucous  membrane  shows  evidence  of 
marked  chronic  inflammation,  long  continued  and  still  quite  ac- 
tive and  there  is  a  great  amount  of  inflannnatory  change  in  the 
bone. 

Clinical  result :  In  9  days  after  operation,  vision  3/30 ;  no 
headache.  In  20  days,  V.  20/38.  In  35  days,  20/19  and  normal 
field;  no  headache. 

March  22,  1915,  V.  20/19  both  eyes. 

Vulgar  Migraine 

Mrs.  M.  D.  A.,  48  years  old,  consulted  me  June  11,  1910, 
because  of  right  side  recurrent  sphenopalatine  ganglion  neu- 
ralgia, or,  at  least,  Avhat  seemed  to  be  such.  It  had  lasted 
twenty-four  years.     It  was   stopped  by   eocainization   of  the 


CASE    HISTORIES  237 

sphenopalatine  gangiion  and  controlled  for  one  year  by  earboli- 
zation  of  the  ganglion,  at  the  end  of  which  time  she  suffered 
some  kind  of  an  explosion  which  took  in  her  entire  head,  upper 
and  lower  part,  on  both  sides,  Avhicli  confined  her  to  her  bed 
for  four  weeks  despite  acetphenetidin,  aspirin,  codeine  and  mor- 
phine. I  did  not  see  her  during  this  illness.  After  this  at- 
tack, however,  she  came  to  see  me,  but  showed  no  local  changes. 
She  continued  to  suffer  very  greatly,  and  frequently  from  what 
seemed,  from  its  distribution,  a  trigeminal  neuralgia  with  pain 
in  her  occiput  and  neck  almost  altogether  on  the  right  side. 
After  a  careful  explanation  of  her  case  to  her,  describing  the 
local  conditions  and  telling  of  a  possible  benefit  from  intra- 
sphenoidal  medication.  Dr.  Bliss  and  I  advised  her  to  submit 
to  the  opening  of  her  sphenoid,  despite  the  fact  that  no  sphe- 
noidal inflammation  betrayed  itself.  She  accepted  the  pro- 
posal. Twice  prior  to  the  Hajek  radical  post-ethmoidal-sphe- 
noidal  operation  I  injected  a  drop  of  5  per  cent  solution  car- 
bolic acid  in  95  per  cent  ethyl  alcohol  into  the  sphenopalatine 
ganglion,  each  being  allowed  to  rest  five  days  with  the  idea  of 
benumbing  it  and  thereb}^  reducing  the  reactionary  shock.  The 
pain  of  the  operation  under  cocaine  and  the  succeeding  depres- 
sion and  pain  were,  in  this  case,  astoundingh^  little.  Subse- 
quent filling  of  the  sphenoid  sinus  with  2  per  cent  sodium 
salicylate  water  solution  has  been  accompanied  by  a  decided 
betterment,  both  in  severity  and  frequency  of  the  pain  on  the 
right  side. 

Vasomotor  Rhinitis  and  Nasal  Gang^lion 

A.  L.,  age  35  years,  consulted  me  on  April  19,  1915,  com- 
plaining of  intractable  sneezing,  great  watery  secretion  and  total 
nasal  obstruction.  She  said  that  she  had  hay  fever  all  the  year 
round.  Examination  showed  a  high  grade  hyperplastic  post- 
ethmoiditis.  The  injection  of  the  nasal  ganglion,  twice  on  each 
side  has  succeeded  in  checking  the  secretion  and  shrinking  the 
swelling  which  gave  rise  to  the  nasal  obstruction.  At  the  time 
of  the  injection  the  swelling  a]3peared  to  be  polypoid-edematous 
swelling  of  the  entire  nasal  cavity.  This  case  is  to  me  of  in- 
terest particularly  showing  ho^^'  sometimes  the  nerve  supply 
will  sometimes  shrink  up  the  edematous  swelling  that  we  oc- 


238  HEADACHES    AND    EYE    DISORDERS    OF    XASAL    ORIGIN 

easioiially  see.  I  liave  other  cases  where  I  tried  to  give  the 
same  treatment  and  succeeded  in  some  and  failed  in  others, 
the  faihire  nsnally  being  to  slirink  np  the  edematous  swollen 
membrane. 

Transitory  Amblyopia 

Mrs.  C.  S.,  aged  25  years,  consulted  me  February  20,  ]  903, 
for  an  acute  pan-sinus  suppuration  with  general  headache. 
Prior  to  this  attack  she  had  very  rarely  in  her  life  been  sick  in 
any  way.  She  did  not  remember  to  have  ever  had  a  bad  head- 
ache, and  had  ahvays  been  strong.  She  has  done  hard  work 
(shoe  machine)  since  her  nineteenth  year.  Since  this  attack 
she  has  had,  up  to  the  present  time  (nine  years),  a  recurrent 
iieadache  that  seldom  skips  more  than  ten  days.  Much  of  the 
time  it  is  frontal,  sometimes  maxillary,  and  often  intense  com- 
bined with  occipital  pain.  It  is  worse  at  night  and  during  men- 
struation. Meanwhile  I  have  opened  the  frontal  sinuses  and 
antra  and  ethmoids  and  sphenoids,  and  done  everything  known 
to  possibly  help  (contacts,  etc.).  I  have  from  time  to  time  put 
her  in  charge  of  specialists  in  all  the  departments  of  medicine, 
who  have  found  her  normal,  save  hyperojiic  astigmatism,  for 
w^hich  she  wears  glasses.  November,  1911,  I  proved  that  her 
trigeminus  Avas  easily  accessible  (intra-sphenoidal)  on  both 
sides.  Since  then  I  have  filled  the  sphenoid  once  in  ten  days 
with  1  per  cent  phenol  in  oil.  She  says  that  this  is  the  first  med- 
ication to  help  her  pain. 

All  characteristics  of  a  nose  case  disappeared  from  this 
patient  by  the  end  of  the  first  three  months. 

1918,  during  the  past  year  she  has  developed  a  transitory 
amblyopia  at  the  height  of  the  headache  which  develops  from 
a  coryza. 

Sphenoiditis  with  Choroiditis — Secondary  Closure  of  Sphenoid 

With  Optic  Neuritis 

Miss  M.  L.,  consulted  me  Sept.  21,  1914,  for  choroiditis, 
report  of  which  I  herewith  attach,  by  Dr.  ^[.  H.  Post.  Exam- 
ination showed  a  post-ethmoidal  sphenoiditis  of  low  grade, 
suppurative  (sero-purulent).  No  mark  of  hyperplasia.  Ten- 
tative treatment  failed  to  relieve  her  condition.    Bilateral  post- 


CASE    HISTORIES  239 

ethmoidal-sphenoidal  operation  was  done.  R.  Sphenoid,  Sept. 
25,  1914,  L.  Oct.  12,  1914,  Avith  recovery  of  vision. 

Tlie  patient  was  Lronght  to  me  again  on  December  15,  1917, 
by  Dr.  A.  E.  Ewing,  for  an  optic  neuritis  of  the  right  eye. 
There  was  a  swelling  of  4  dioptres.  Examination  showed  the 
sphenoid  cavity  of  the  right  side  totally  closed  by  a  membranous 
formation,  Avhich  Avas  at  once  opened;  Avith  the  result  that  the 
improA^ement  of  Adsion  Avas  immediate. 

Ophthalmological  notes  by  Dr.  A.  E.  EAving. 

Pain  in  right  eye  during  the  last  ten  days. 

0.1).  V.  =  20/20.     O.S.  Y.  =  20/20. 

Pain  relieA^ed  by  general  treatment. 

1914,  Sept.  0.  D.  sore  for  about  four  Aveeks.  Vision 
''blurred." 

O.D.  Y.  -  3/75.     O.S.  Y.  =  20/20. 

O.D.  Numerous  areas  of  pigment  deposit  and  Avhite  swell- 
ing Avitli  atrophy  of  choroid  in  upper  nasal  portion  of  the  fundus. 
These  are  also  edematous  SAvellings  of  the  retina. 

O.S.  Condition  similar  but  less  marked  is  mainly  in  loAver 
nasal  portion  of  the  fundus. 

Treatment,  KI,  increasing  doses. 

O.D.  Three  large  nearly  constant  scotomata  in  field. 

O.S.  Field  normal. 

Sept.  21.  Comj^lains  of  black  spot  at  center  of  A^sion  O.S. 

O.D.  Y.  =  20/150.     O.S.  Y.  =  20/75. 

Sept.  27.  Operated  upon  by  Dr.  Sluder. 
Oct.  30.  O.D.  Y.  =  20/150.     O.S.  Y.  =  20/30. 
Ophthalmoscope  shows  very  little  change. 
Dec.  7.  O.D.  Y.  =  20/96.     O.S.  Y.  =  20/20. 
Each  fundus  more  cpiiet. 

1915,  Jan.  18.  O.D.  Y.  =  20/38.     O.S.  Y.  =  20/20. 

O.D.  Condition  of  fundus  improA^ed,  but  there  are  a  number 
of  fine  hemorrhages. 
O.S.  Fundus  quiet. 

March  29.  O.D.  Y.  =  20/27.     O.S.  Y.  =  20/20. 
O.D.  Fundus  A^ery  quiet. 
O.S.  Fundus  A^ery  quiet. 


240  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

1917,  Nov.  27.  Return  of  "blurred  vision"  O.D.  for  about  a 
week.  O.D.  V.  =  20/192.  O.S.  V.  =  20/15.  O.D.  Marked  neuro- 
retinitis,  disc  margiiis  not  definable.  Swelling  of  disc  measured 
])y  4d. 

Referred  to  Dr.  Sluder. 

Dec.  6.  O.D.  Y.  =  20/75.     Disc  less  swollen. 

1918,  Jan.  18.  O.D.  V.  =  20/38.     Disc  nearly  normal. 
(Not  seen  since  this  data.) 

Many  times  have  I  seen  sphenoid  cases  re-develop  the  eye 
troul)le  under  acute  coryza  or  closure  of  the  cell;  Irat  they 
have  always  been  the  same  lesion,  that  is,  sphenoiditis  that 
made  a  choroiditis  on  one  occasion  under  the  influence  of  a  cor- 
yza or  closure  has  re-developed  a  choroiditis  again.  This  is  the 
only  case  in  which  a  choroiditis  of  both  eyes  Avas  the  primary 
lesion,  which  was  followed  by  an  optic  neuritis  from  closure  of 
the  sinus  two  years  later. 

Death  from  Meningitis 

Mrs.  Buc,  40  years  old,  consulted  the  Nose  and  Throat 
Clinic,  0 'Fallon  Dispensary,  AYashington  University  Medical 
Department,  for  severe  headache,  worse  on  left  side,  extending 
to  neck  and  shoulders.  All  examination  was  negative.  After 
considerable  effort  I  determined  a  loost-ethmoidal-sphenoidal 
inflammation  R.  and  L.,  and  later,  February-July,  1910,  opened 
both  sides.  Tiie  reaction  was  severe.  After  some  months  she 
was  better,  and  finally  became  comfortable.  A  coryza  Avithout 
suppuration  later  re-established  the  pain,  which  on  the  right 
side  was  stopped  by  intrasphenoidal  applications  of  10  per  cent 
salicjdate  of  methyl,  and  much  improved  on  the  left  side.  Ap- 
plications of  cocaine  inside  the  left  sinus  quickly  produced  total 
anaesthesia  and  analgesia  of  the  areas  supplied  by  all  the  divi- 
sions of  the  fifth  nerve,  with  a  marked  sense  of  stiffness  of  the 
loAver  jaw  of  that  side,  which  I  took  to  be  the  effect  of  the  co- 
caine upon  the  motor  function  in  the  third  division.  Dr.  D.  E. 
Jackson,  of  the  Pharmacological  Department,  Washington  Uni- 
versity, agrees  with  me  in  this  conclusion.  The  right  side  ceased 
to  be  painful  six  months  ago  (1912),  which  is  shortly  after  the 
applications  of  methyl  salicylate  were  begun.  The  left  contin- 
ues to  be  intermittently  painful  to  a  considerable  degree,  but 


CASE    HISTORIES  241 

is  markedh'  helped  by  inetliyl  salieylato,  and  remains  vastly 
better  than  before  this  treatment  was  begun.  She  frequently 
complains  of  stiffness  of  the  lower  jaw  on  that  side.  Only  once 
did  this  case  show  a  tendency  toward  edema  with  polyp  forma- 
tion at  the  time  of  acute  inflammatory  attack,  and  then  only 
slight. 

Intra-sphenoidal  observation  in  this  case  at  the  time 
(1914)  of  the  severe  ear  pain  has  sliown  greatly  reddened  Vid- 
ian and  maxillary  tract.  As  the  pain  subsides,  tlie  redness  of 
these  districts  disappears;  or  as  the  redness  disappears,  the 
pain  subsides.  Cocainization  within  the  sphenoid  is  uniformly 
satisfactory — it  stops  the  pain.  Application  of  strong  cocaine 
dropped  within  the  sphenoid  paralyzes  the  entire  fifth  nerve 
distribution  for  sensation,  with  a  stiffness  of  the  lower  jaw. 

She  continued  to  improve  under  treatment,  seemingly  do- 
ing well  until  Dec.  15,  1915,  when  her  husband  telephoned  that 
she  had  had  a  very  violent  headache  that  day ;  and  that  evening 
began  to  vomit  without  any  preceding  nausea.  I  immediately 
suspected  an  intra-cranial  disturbance,  and  sent  to  have  the 
case  examined. 

My  assistant  reported  that  the  internal  medical  man  had 
determined  that  it  was  gallstone :  and  that  the  case  seemed  to 
be  one  of  gallstone,  and  tliat  she  seemed  very  much  better. 

Most  unfortunately,  an  accident  in  my  affairs  at  that  time 
delayed  me  four  days  in  my  effort  to  keep  in  touch  ^^'ith  the 
progress  of  the  case.  At  the  end  of  this  time,  I  was  informed 
that  she  had  developed  a  meningitis  and  had  been  sent  to  the 
infectious  hospital. 

Inquiry  was  made  there  concerning  the  case.  It  was  re- 
ported that  she  had  died;  but  that  no  autopsy  had  been  per- 
formed. 

Examination  of  tlie  spinal  fluid  had  been  negative. 

The  case  seems  unquestionably  to  be  one  of  extension  to 
the  cranial  cavity  from  the  sphenoidal  sinus.  It  was  most  un- 
fortunate that  I  could  get  no  autopsy  report. 

In  my  experience  I  have  had  eight  case^  to  follow  more  or 
less  their  course,  that  have  ended  by  some  mysterious  menin- 
geal process.  One  proved  to  be  a  glioma  of  the  middle  fossa 
of  the  skull.    It  developed  about  a  year  after  the  sphenoid  op- 


242  HEADACHES    AXD    EYE    DISORDEES    OF    NASAL    OFJGIX 

eration  wliieli  liad  saved  both  eyes,  and  a  liigli-grade  optic  neu- 
ritis. 

Paralysis  of  the  Trochlearis  with  Dilated  Pupil 

Miss  M.  R.,  21  years  old,  consulted  me  March  24,  1912,  be- 
cause of  mild  posterior  headache  Avitli  dilatation  of  the  pupil 
on  the  right  side,  accompanied  by  discomfort  in  use  of  her  eyes, 
of  one  week's  standing.  Ophthalmological  examination  was 
negative.  An  upright  rod  appeared  to  her  bifurcate  below, 
which,  I  understand,  indicates  a  paresis  of  the  superior  oblique. 
The  anterior  wall  of  the  right  half  of  the  sphenoid  was  red- 
dened and  l)athed  in  serum.  The  effort  was  made  to  fill  the 
sinus  with  li/o  per  cent  sodium  salicylate  Avater  solution.  This 
was  repeated  three  times  in  nine  days,  when  she  was  free  of  all 
signs  and  symptoms,  and  remained  so  ten  days,  when  she  had 
a  "sick  headache"  (in  which  I  did  not  see  her)  and  again  had  a 
dilated  pupil  which  became  normal  when  the  headache  stopped. 
Xo  discernible  cause  could  be  assigned  for  the  sick  headache. 

Beginning'  Optic  Atrophy 

0.  R.,  15  years  old,  strong,  healthy  l)oy,  referred  by  Dr.  A.  E. 
Ewing,  May,  1911,  for  beginning  optic  nerve  atrophy,  which  had 
lasted  one  year.  My  diagnosis:  Hyperplastic  sphenoiditis,  R. 
and  L.,  not  far  ad^'anced,  non-suppurative.  Dr.  Ewing 's  report, 
vision  R.  E.  20/192,  L.  E.  20/150  Avith  small  central  scotoma  R. 
Right  eye  showed  narrow  pigmented  crescent  to  temporal  side 
of  disc  and  more  to  temporal  side ;  no  headache.  He  was  given 
a  21/4  per  cent  alkaline  saline  solution  to  pour  into  nose  3  times 
a  day  Avith  a  phenol  spray.  In  5  months  he  shoAved  V.  20  60  R. 
and  L.,  Iavo  eyes  20/38.  I  have  had  a  similar  case  Avitli  Dr. 
EAving  in  a  Avoman  72  years  of  age. 

Sphenoidal  Headache  with  Probably  a  Migraine  Added 

Miss  A.  M.,  38  years  old,  consulted  me  March  20,  1911,  be- 
cause of  intermittent  headache  from  Avliich  she  had  suffered 
years.  At  this  time  it  had  been  coming  much  oftener  and  has 
been  rapidly  groAving  more  seA^ere,  then  recpiiring  2i^  grains 
of  morphine  sulphate  subcutaneously  administered  by  her  phy- 
sician to  control  the  jiain.     She  neA'er  took  morphine  herself. 


CASE    HISTOKIES  243 

The  pain  was  worse  in  left  temple ;  but  in  the  height  of  the  at- 
tack it  seemed  to  extend  over  the  entire  head.  And  very  rarely 
it  came  on  the  right  side  alone  or  would  be  much  worse  on  that 
side.  A  post-ethmoidal-sphenoidal  inflammation  was  found  on 
the  left  side,  which  Vv^as  operated  two  months  later.  The  reac- 
tion was  intense.  She  improved  little  or  none  during  the  next 
four  months  under  a  treatment  of  simple  cleansing  of  the  cav- 
ities. At  this  time  (October,  1911),  intra-sphenoidal  applica- 
tions of  10  per  cent  methyl  salicylate  were  begun  with  the  idea 
of  soaking  the  medicament  into  the  environing  fifth  nerve. 
Since  then  the  general  improvement  in  her  suffering  has  been 
very  considerable.  ]\lucli  of  the  time  she  is  free  of  pain  and  a 
large  jDart  of  the  remaining  time  she  suffers  onh^  slightly.  The 
recurrence  of  the  intensely  severe  attacks  is  less  frequent  and 
intense.  She  recognizes  two  kinds  of  pain — one  that  I  can  stop 
by  filling  the  sphenoid  sinus  with  cocaine  methyl  salicylate  or 
menthol  solutions  and  another  distributed  over  the  same  area 
which  I  have  tried  in  vain  to  stop  by  these  measures.  AVhen 
this  attack  begins  it  progresses  despite  all  efforts  to  stop  it; 
but  it  has  become  less  severe  and  less  frequent  under  this  treat- 
ment, and  the  last  attack,  April  1,  1912,  was  on  the  right  side 
only. 

Glaucoma  and  the  Nasal  Ganglion 

Mr.  R.,  age  50  years,  consulted  me  the  June  of  1913,  re- 
ferred by  Doctor  Ewing,  complaining  of  great  pain  in  the  eye 
which  had  been  lost  by  glaucoma.  The  conjunctiva  was  greatly 
swollen  red  and  the  eye  socket  appeared  to  be  fuller  than  the 
opposite  fellow.  Full  anaesthesia  of  the  nasal  ganglion  re- 
lieved the  pain.  This  Avas  carried  out  daily  for  three  weeks, 
at  the  end  of  which  time  the  swelling  of  the  conjunctiva  and 
its  redness  and  all  of  the  joain  in  his  eye  had  subsided.  His 
eye  looked  at  that  time  like  the  eye  of  the  opposite  side — nor- 
mal. This  case  is  to  me  exceedingly  interesting  showing  the 
power  exerted  over  the  eye  from  the  nasal  ganglion.  AVhether 
this  be  a  trophic  influence  or  whether  it  be  the  result  of  the 
control  of  pain  is  to  me  very  difficult  to  decide.  I  am  undecided 
as  to  which  it  is.  It  would  apj^ear,  every  now  and  then,  that 
the  influence  is  a  trophic  one.    The  cocainization  of  the  ganglion 


244  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

in  this  case  was  accoinplislied  first  with  a  drop  of  90  per  cent 
sohition  whicli  was  afterwards  reduced  to  a  daily  application 
of  20  per  cent.  It  is  impossible  for  me  to  conceive  of  this  case 
as  being  influenced  through  the  lymphatics,  that  is,  the  infec- 
tion; or  assuming  tliat  the  infection  is  controlled  by  way  of  this 
channel.  Many  times  have  I  obtained  a  most  l)eneficial  result 
for  the  eye  condition  where  the  ophthalmologist  was  having  a 
hard  time  to  control  a  bad  iritis.  Full  anaesthesia  to  the  nasal 
ganglion  has  sto^^ped  the  pain  and  the  iritis  has  repeatedly  im- 
proved from  that  time  on.  The  lesion  within  the  nose  in  these 
cases  has  been  almost  uniformly  a  thick  velvet-like  swelling  of 
the  posterior  tip  of  the  middle  turbinate  and  just  above  it,  that 
is,  a  hyperplastic  post-ethmoidal  inflammation.  The  applica- 
tion of  this  small  amount  of  cocaine  to  this  district  does  not 
seem  possible  to  me  to  have  any  controlling  x^ower  over  the  in- 
fection. 

Nasal  Ganglion  Injection  Failure 

Mrs.  G.  was  seen  by  me  in  the  Hopkins  Hospital  on  Oct.  15, 
1909,  Avith  what  seemed  to  be  a  high  grade  nasal  ganglion 
neuralgia.  She  was  presented  to  me  by  Doctor  Harvey  Gush- 
ing. Prior  to  my  examination,  however.  Doctor  Bordely  had 
operated  the  sphenoidal  district.  I  injected  the  nasal  ganglion 
or  at  least  attempted  to  inject  it  in  the  acute  inflammatory 
reaction  which  followed  Doctor  Bordely 's  surgery.  The  result 
Avas  a  failure.  Doctor  dishing  later  removed  the  semilunar 
ganglion.  In  this  case  the  straight  needle  as  I  passed  it  in, 
went  an  unusual  distance.  My  feeling  about  it  noAV  is  that  the 
sphenoidal  face  w^as  unusually  thin  and  I  crossed  the  spheno- 
maxillary fossa  to  inject  into  the  cavity  of  the  sphenoid. 
AVhether  the  injection  of  the  sj)henoinaxillary  fossa  at  that  time 
would  have  been  helpful  or  not  of  course  I  cannot  say.  It 
is  a  failure  the  anatomical  explanation  of  which  is  given  in  the 
preceding  text. 

Sphenoiditis  with  Pain  in  the  Shoulder  Blades 

Mr.  B.  A.,  age  35  years,  consulted  me  March  7,  1914,  com- 
plaining of  very  severe  pain  between  his  shoulder  blades.  He 
was  sent  to  me  by  Doctor  M.  A.  Bliss  who  said  that  he  thought 


CASE    HISTORIES  245 

that  he  suffered  from  a  sphenoidal  disturhaiiee.  Examination 
of  the  nose  at  that  time  Avas  negative.  Continued  effort  for  a 
diagnosis  was  successful  for  some  little  time  bnt  later  a  defi- 
nite sphenoiditis,  low  grade  suppurative  was  determined  and 
opened.  The  "ball  of  fire"  as  the  patient  described  the  pain 
in  this  case  was  fortunately  relieved  rather  quickly;  in  ten  days 
it  subsided,  and  has  not  returned.  The  case  is  interesting  to  me 
sliowing  the  intensity  of  a  single  symptom  in  connection  with 
these  lesions.  The  majority  of  the  lesions  are  accompanied  by 
a  number  of  manifestations.  This  case  complained  only  of  vio- 
lent burning  pain  between  his  shoulder  blades. 

Acute  Post-ethmoidal  Blindness 

W.  n.,  20  years  old,  strong,  healthy  man,  referred  by  Dr. 
^y.  H.  Luedde,  July  22,  1907.  My  diagnosis:  Acute  post-eth- 
uKnditis,  suppurati\e  with  edema.  He  had  presented  himself 
to  Dr.  Luedde  that  day,  saying  that  "three  days  ago  the  present 
trouble  began  with  a  sharp  pain  in  right  eye;  12  hours  later 
a  slight  swelling  appeared  around  this  eye  which  lasted  12 
hours.  The  pain  continued  until  today."  This  morning  at 
7 :30  both  eyes  became  blind.  The  left  eye  remained  blind  about 
25  minutes.  The  right  eye  can  see  direction  of  motions  of  hand 
3  feet,  vision  of  left  eye  15-19  by  artificial  light.  Examination 
showed  the  right  upper  meatus  of  the  nose  swollen  shut  and 
pale  (edematous).  No  pus  could  be  discovered.  Effort  was 
made  to  shrink  away  the  swelling,  which  was  only  in  small 
part  successful.  He  was  placed  in  St.  Luke's  Hospital  and 
the  effort  repeated  at  midniglit,  unsuccessfully.  It  was  repeated 
at  6  A.M.,  July  23,  1907,  and  followed  l)y  the  discharge  of  about 
a  teaspoonful  of  pus  into  the  throat.  Three  hours  later  (9  a.m.) 
he  reported  to  Dr.  Luedde,  who  found  the  vision,  right  eye 
15/19,  left  eye  15/12.  The  discharge  of  pus  continued  inter- 
mittently, stopping  in  ten  days.  It  alwaj^s  appeared  between  the 
middle  and  upper  turbinates.  Never  did  any  appear  in  the 
recessus  spheno-ethmoidalis.  Four  days  from  tlie  beginning  of 
the  treatment  the  ]"iglit  upper  meatus  swelled  sJiut  again  for 
a  feAv  hours  (about  six  hours)  the  pain  recurred  to  a  slight  de- 
gree and  his  vision  in  the  right  eye  fell  temporarily  from  15-12 


246  HEADACHES   AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

to  15-24  for  this  length  of  time.    From  the  tenth  day  he  remained 
normal  in  every  way  and  continues  so  at  present. 

Conjunctivitis 

H.  H.  F.,  32  years  old,  strong,  normal  man,  consulted  me 
March,  1912.  He  had  an  intractable  low  grade  conjunctivitis, 
which  was  left  in  the  wake  of  a  ''bad  cold  in  his  head,  four 
years  ago."  Every  coryza  makes  it  worse.  Cauterization  of 
the  sphenopalatine  foramen  membrane  Avith  trichloracetic  acid 
four  times  at  two-week  intervals  gave  prolonged  relief.  Coryzas 
rekindle  the  trouble,  but  he  comes  to  be  comfortable  again  in  a 
short  time. 

Sympathetic  Pain 

Mrs.  A.  E.  consulted  me  October  10,  1916,  because  of  head- 
ache, which  in  degree  I  think  surpassed  probably  anything  that 
is  the  fate  of  the  ordinary  rhinologist  to  meet.  It  was  severe  in 
the  extreme.  She  gave  the  history  of  having  the  pain  for  many 
years.  She  had  consulted  many  physicians  because  of  it.  Fi- 
nally, Dr.  Harvey  Gushing  removed  the  semilunar  ganglion  for 
the  relief  of  this  pain.  The  operation  Avas  followed  by  total 
loss  of  sensation  for  the  distribution  of  the  trigeminus ;  but  the 
pain  persisted  with  great  severity.  Examination  of  the  nose 
shoAved  a  A^olently  inflamed  sphenoid,  Avhich  Dr.  Thigpin  of 
Alabama  recognized.  He  sent  her  to  me,  Avitli  the  idea  that 
the  injection  of  the  nasal  ganglion  might  be  helpful.  Experi- 
ment Avith  the  ganglion  shoAved  absolutely  no  influence  upon  the 
pain.  It  Avas  therefore  decided  to  open  the  sphenoid,  Avhich  Avas 
attempted  by  the  angle  knife;  but  the  l)one  Avas  so  hard  that 
it  could  not  be  cut  through.  I  then  drilled  by  means  of  a 
straight  hand  drill  into  the  sphenoidal  sinus,  and  fomid  upon 
entrance  a  small  quantity  of  bloody  serous  fluid,  probably 
more  serum  than  blood.  The  headache  stopped  almost  at  once 
and  remained  so  three  days,  at  the  end  of  Avhich  time  it  began 
to  re-appear  and  developed  into  its  original  severity. 

The  opening  made  by  the  drill  into  the  sphenoid  Avas  not 
more  than  3/16  of  an  inch  in  diameter,  and  it  very  soon  closed 
up  and  re-established  the  headache.  I  tried  to  persuade  the 
patient  to  remain  in  St.  Louis  and  give  me  more  opportunity 


CASE    HISTORIES  247 

to  treat  the  case,  but  she  was  uiialjle  to  do  this.  She  returned 
to  Alabama.  Dr.  Thigpin  reiDorted  that  the  j)ain  was  quite  as 
severe  as  ever. 

This  case  interests  me — seems  to  me  to  be  iUustrative  of 
the  fact  that  the  sympathetic,  when  irritated,  may  produce 
great  pain.  Furthermore,  that  it  may  produce  pain  for  a  Avide 
distribution ;  for  this  was  not  merely  a  lower-half  headache,  al- 
though it  was  very  violent  in  tlie  lower  half,  at  the  same  time 
it  involved  the  entire  skull. 

In  this  case  the  semilunar  ganglionectomy  by  Dr.  Gushing 
was  faultless,  according  to  the  observation  of  Dr.  Bliss,  upon 
the  peripheral  phenomena.  In  the  begiuning  of  my  observation 
of  the  clinical  cpiestions  of  the  nasal  ganglion  Dr.  Gushing 
showed  me  six  cases  more  or  less  similar  to  this  one. 

Supraorbital  and  Nasal  Ganglion  Neuralgia 

Mrs.  L.,  42  years  old,  came  to  me  August  3,  1908,  complain- 
ing of  pain  behind  the  right  e^^e  and  in  the  upper  jaw,  (all 
sinuses  normal).  She  described  the  pain  as  constant.  She 
stated  that  she  had  for  thirty  years  been  subject  to  violent 
headaches,  ending  in  vomiting.  This  case  was  diagnosticated 
as  migraine  by  Dr.  F.  E.  Fry,  who  sent  her  to  me.  A  little  later 
I  saw  her  in  one  of  her  "bad  spells."  The  pain  was  very  great. 
It  took  in  the  entire  half  of  the  right  side  of  the  head  and  ran 
down  into  the  neck,  shoulder  blade,  axilla,  arm,  forearm,  and 
hand.  A  drop  of  saturated  solution  of  cocaine  was  then  soaked 
into  the  site  of  the  sphenopalatine  foramen  with  marked  re- 
lief except  of  the  pain  in  the  upper  half  of  the  head  (ophthalmic 
nerve).  A  second  application  was  then  made  with  complete  re- 
lief of  all  the  pain  except  that  of  the  upper  half  of  the  head, 
which  remained  unchanged.  The  relief  afforded  in  this  attack 
lasted  about  an  hour,  at  the  end  of  which  time  the  pain  had  re- 
turned just  as  it  had  been.  I  saw  her  in  two  more  "bad  spells," 
the  histories  of  which  were  identical  with  tlie  one  given.  Each 
time  cocainizing  over  the  ganglion  stopped  all  the  pain  except 
that  of  the  upper  half  of  the  head,  and  the  relief  lasted  about 
an  hour. 

Applications  of  14  per  cent  formaldehyde  vrere  continued 
over  a  period  of  four  months;  the  pain  behind  the  eye  and  in 


248  HEADACHES   AXD    EYE    DISORDERS    OF    N^ASAL    ORIGIN 

the  jaw  liaying-  stoi)ped  in  four  weeks,  for  the  most  part.  It 
occasionally  returned  in  a  lesser  degree.  The  intervals  between 
the  "bad  spells"  became  longer  and  their  severity  lessened.  This 
case  slioAvs  an  involvement  of  the  ophthalmic  nerve  as  well  as 
the  nasal  ganglion. 

Transitory  Amblyopia 

Mrs.  A.  A.  B,,  30  years  old,  consulted  me  October  1,  1917. 
She  had  had  for  six  months,  great  swelling,  sneezing,  Avatery 
discharge,  with  tearing  eyes  and  intense  headache,  chiefly  pos- 
terior, accompanied  by  a  transitory  heavy  gray  mist,  appearing 
ing-  before  her  eyes,  and  lasting  for  periods  of  twenty  minutes 
to  an  hour  almost  every  day.  Ophthalmoscopic  examination 
by  Dr.  F.  L.  Henderson  was  negative.  Examination  showed  a 
gray  spot  in  the  sphenoethmoidal  recess,  right  and  left,  at  the 
site  of  the  sphenoidal  opening,  with  a  distinctly  enlarged  and 
inflamed  posterior  tip  of  the  middle  turbinate  on  the  left  side 
(hyperplastic  post-ethmoiditis),  with  acute  process  added  on. 
The  gray  spots  were  the  outlets  of  the  sphenoidal  sinus,  and 
probably  a  trace  of  secretion  which  was  not  perfectly  clear. 

The  effort  of  tentative  treatment  failed  and  on  the  post- 
ethmoidal-sphenoidal  operation  was  iDerformecl  on  the  left  side. 
The  nose  was  very  tall  and  very  narrow,  and  presented  a  tech- 
nical difficulty  probably  as  great  as  such  noses  ever  present. 

The  result  Avas  that  the  headache  stopped  at  once  and  the 
"blind  spells"  also  stopped  and  have  not  returned  to  date. 

Examination  of  removed  tissue  has  not  yet  been  made. 

Clinically,  the  case  appeared  to  be  a  Ioav  grade  hyperplas- 
tic post-ethmoidal  sphenoiditis,  Avith  a  Ioav  grade  subacute  in- 
flammation added  upon  it. 

The  case  is  interesting,  combining  headache  Avith  a  transi- 
tory appearance  of  mist  or  steam  AA-hich  she  described  as  blind- 
ness. No  opththalmoscopic  explanation  for  this  could  be  found. 
I  have  seen  this  phenomenon  often  develop  after  the  case  Avas 
several  years  old.  The  secretion  and  probably  the  tearing  and 
sneezing  Avere  manifestations  on  the  part  of  the  sympathetic 
fibres  of  the  Vidian  nerve. 


CASE    HISTORIES  249 

Neck  Pain 

J.  AV.  v.,  40  years  old,  eanie  to  me  December  15,  1915,  com- 
plaining of  a  windpipe  cough,  with  a  lingnal  tonsillitis.  He 
also  gave  the  history  of  very  severe  stiffness  of  both  shoulders, 
which  he  had  had  for  15  years.  He  was  a  strong  athlete  Avho 
delighted  in  Avater  polo,  and  always  felt  that  the  stiffness  of  his 
shoulder  was  in  some  wise  connected  with  the  exercise  of  that 
game.  Cocainization  of  the  ganglion  stopped  the  stiffness  of 
his  shoulder;  and  so  it  was  decided  to  inject  the  ganglia;  both 
of  which  have  now  been  injected  three  times.  He  is  comfort- 
able at  all  times,  except  that  of  a  coryza— then  some  discomfort 
in  his  shoulders  redevelops. 

The  coryza  for  this  patient  is  uniformly  a  suppurative 
post-ethmoidal  sphenoiditis  of  high  grade.  It  does  not  make 
headache  and  recovers  as  an  ordinary  cor^^za,  and  Avlien  recov- 
ered, leaves  no  mark  in  its  Avake.  For  that  reason,  I  have  so 
far  not  determined  u])on  any  surgery  more  than  the  injection 
of  the  nasal  ganglia. 

Hyperplastic  Sphenoiditis  and  Pregnancy 

Mrs.  S.,  aged  28  years,  consulted  me  Jan.  3,  1915,  because 
of  lower-half  headacre.  Examination  revealed  a  Ioav  grade  hy- 
IDeiplastic  post-ethmoidal  sphenoiditis  right  and  left.  Inquiry 
revealed  further  that  she  was  iDregnant  three  months.  The  state- 
ment Avas  made  that  the  headache  had  begun  only  Avith  the 
pregnancy.  As  an  unpregnant  Avoman  she  did  not  suffer  head- 
ache. Subsequent  pregnancies,  tAvo  in  number,  rcA^ealed  that 
Avitli  each  pregnancy  the  process  becomes  actiA^e,  sufficient  to 
make  pain  and  subsides  again  later  Avhen  the  uterus  is  empty. 
The  case  is  of  interest  in  shoAving  the  increased  activity  of  the 
parts  during  pregnancy.  It  ayjpears  to  be  a  Ioav  grade  case. 
She  suffers  little  or  none  except  AA^hen  aroused  under  those 
conditions. 

Lifetime  Headache  with  Loss  of  Vision  at  54  Years  of  Age 

W.  K.,  56  years  old,  referred  by  J.  AV.  Cliarles,  March  9, 
1914.  My  diagnosis :  Hyperplastic  sphenoiditis  with  scant  se- 
cretion on  right  side.    States  that  he  has  had  seA^ere  headaches 


250  HEADACHES   AXD    EYE    DISORDERS    OF    NASAL    ORIGIN" 

"all  of  his  life"  of  right  side.  In  one  attack  which  I  saw  it  was 
of  great  severity  in  temple,  al)out  eye,  and  in  occiput  and  neck. 
This  attack  was  accompanied  by  the  loss  of  2  letters  on  the  vision 
test  card,  yawning,  drowsiness  and  withal  a  marked  restlessness 
which  compelled  him  to  get  out  of  bed  in  the  middle  of  the  night, 
also  by  vertigo,  nausea,  vomiting,  pallor  and  sweat.  The  next 
day,  the  attack  lieing  over,  the  pain  sense  was  still  better  E. 
but  not  the  sense  of  taste.  He  had  regained  the  two  letters 
he  had  lost.  A  hyperalgesia  11.  with  more  acute  sense  of  taste 
R.  after  July  7,  1914.  Dr.  Charles'  report:  In  1903  he  showed 
a  hyperopia,  2d,  R.  eye  and  2.5  L.  eye.  Vision  15/714  R-  and 
L.  By  ophthalmoscope  both  eyes  normal.  In  1912  R.  eye  V. 
13/40."^  In  1913  V.  1350.  1914,  July  1,  V.  23/192  and  some 
clouding  of  vitreous.  Unusually  severe  headaches ;  disc  l)lurred. 
July  7,  1914.  Post-ethmoidal-sphenoidal  operation,  after 
Avhich  the  headaches  stopped  altogether  and  his  color  became 
normal  (his  appearance  prior  to  this  was  evidently  that  of  a  low 
grade  sepsis).  Vision  August  11,  23/38,  the  last  time  he  ap- 
]3eared  for  examination.  By  telephone  he  says  he  is  all  right 
and  gained  18  pounds,  June  1,  1915. 

Vasomotor  Rhinitis 

Miss  E.  C,  28  years  old,  consulted  me  June,  1914,  because 
of  "hay  fever"  (paroxysmal  sneezing  with  secretion),  which 
had  lasted  uninterruptedly  six  years,  accompanied  by  constant 
discomfort  referred  to  her  eyes  with  slight  constant  lacrimation 
and  slight  Vidian  neuralgia  (see  above)  Avliich  was  intermittent 
and  sometimes  severe.  She  had  a  low  grade  (non-suppurative) 
hyperplastic  sphenoiditis.  l)ut  the  entire  symptom-complex  Avas 
controllable  from  the  nasal  ganglion  which  I  injected  with 
j)henol-alcoliol  with  relief  of  all  symptoms,  now  for  one  year. 

A  Failure 

R.  B.,  strong,  healthy  man,  21  years  old,  referred  by  Dr. 
H.  8.  Hughes.  My  diagnosis :  Hyperplastic  sphenoiditis, 
non-suppurative.  Dr.  Hughes'  report:  July  20,  1914,  patient 
says  his  vision  was  normal,  that  he  never  had  any  eye  trouble 
until  one  month  ago,  A\hen  he  noticed  the  small  prints  seemed 


CASE    HISTORIES  251 

blurred  and  that  lie  could  not  do  liis  work  with  facility.  No 
other  especial  low  grade  headache.  General  history,  practically 
negative.  Denies  luetic  history  or  any  other  trouble  of  a  general 
nature.  Smokes  little,  about  one  package  of  tobacco  a  week. 
Does  not  drink  to  excess.  External  eye,  normal.  Vision  R.  E. 
6/12;  L.  E.,  2/50  not  improved  with  glasses.  Ophthalmoscope, 
L.  E.,  nerve  head  seems  hazy  in  outline  throughout.  Disc  mar- 
gin being  completely  lost  from  5  to  8  o'clock.  Temple  quad- 
rant is  distinctly  pale.  At  the  lower  nasal  quadrant  are  sev- 
eral very  minute  hemoniiages.  The  macula^  region  looks  hazy 
and  slightly  edematous.  The  retinal  ^'essels  at  lower  disc  mar- 
gin similar  to  that  found  in  left,  except  very  much  less  pro- 
nounced. Optic  nerve  pale.  August  4,  1914,  Dr.  Gradwohl 
reports  negative  Wassermaim  but  a  positive  Hecht-Weinberg. 
Fields  for  form  show  concentric  contraction  varying  from  20  to 
40  degrees.  Diagnosis :  Neuro-retinitis ;  patient  placed  upon 
energetic  alterative  treatment,  supported  with  strychnia.  Vis- 
ion R.  E.,  6/40;  L.  E.,  Fings.  IM.  July  29,  1914,  Dr.  Sluder 
opened  left  sphenoidal  sinus.  August  4,  1914,  vision  R.  E.,  6/50; 
vision  L.  E.,  Fings.  IM.  Accurate  fields  difficult  to  take.  Octo- 
ber, 1914,  R.  E.  Fings.  2M.  This  is  the  last  visual  record  I  was 
able  to  take  of  the  patient.  Subsequent  letters  from  his  family's 
physician  at  Springfield,  IMo.,  would  indicate  that  his  vision  for 
several  months  following  the  above  date  remained  about  the 
same, 

August  7,  Dr.  A.  E.  Ewing  sa^^  the  patient  in  consultation. 
Dr.  Ewing 's  opinion  substantiated  my  own  as  regards  diag- 
nosis and  treatment.  He  did  not  think  there  was  any  indi- 
cation for  specific  treatment  but  suggested  that  the  nasal  treat- 
ment be  continued, 

Post-ethmoidal-sphenoidal  operation,  July  29,  1914, 

Dr.  Wright's  report  of  changes  in  the  sphenoidal  wall  and 
middle  turbinate  reveals  a  moderate  degree  of  hyperplasia  of 
fibrous  connective-tissue  beneath  the  epithelium  and  moderate 
hyperplasia  of  the  bone. 

I  know  of  no  particular  reason  for  the  total  failure  to  im- 
prove this  case. 


252  HEADACHES    AND    EYE    DISORDERS    OF    NASAL    ORIGIN 

Operative  Disaster 

A  liealtliy  boy,  W.  K.,  20  years  of  age,  began  to  lose 
vision  two  weeks  prior  to  consnltation  with  me.  His  oplithal- 
niologist  recognized  an  optic  neuritis  of  3  diopters  swelling. 
Xasal  examination  showed  a  sub-acnte  sphenoiditis  Avith  very 
scant  secretion.  The  proposal  was  made  to  open  the  sphenoid 
at  once ;  but  he  declined  stating  that  he  did  not  care  to  remain 
in  the  city.  His  physician  took  him  away;  and  the  next  day 
operated,  removing  the  middle  turbinate  and  proceeding  back- 
wards in  the  effort  to  exenterate  the  post-ethmoidal-sphenoidal 
cells.  He  succeeded  in  opening  the  post-ethmoidal  district  quite 
well,  but  he  some  way  failed  to  open  the  sphenoid  and  two 
weeks  later  brought  the  boy  back.  His  vision  upon  the  first 
visit  was  20/30.  Upon  his  return  he  had  only  the  perception 
of  light.  Upon  the  second  visit  the  sphenoid  was  opened  com- 
prehensively. Vision  slowly  returned.  In  three  months  it  be- 
came normal.  The  case  is  of  interest  to  me  showing  how  the 
surgery  of  this  district  in  order  to  be  successful  must  l)e  right. 

Miss  B.  C.  consulted;  me  April  29,  1918,  submitted  by 
Doctor  Ewing,  she  being  a  patient  of  Doctor  Saner,  who  kindly 
permitted  my  examination.  She  gave  a  history  that  slie  had 
some  headache  and  eye  disturbance  a  year  prior,  when  one  of 
her  acquaintances,  she  being  a  trained  nurse,  proposed  to 
operate  upon  her  nose.  Slie  was  put  under  ether  and  tlie  opera- 
tion i^erformed.  When  she  came  out  from  the  ether  slie  was 
totally  blind  in  the  right  eye.  Great  hemorrhage  filled  the  right 
eye  socket.  Doctor  Ewing  reported  that  at  present  the  retinal 
arteries  appeared  as  white  silk  threads,  an  appearance  which  he 
is  somewhat  at  a  loss  to  explain.  To  me  the  case  seems  to  have 
been  one  of  those  great  misfortunes  in  which  the  optic  nerve 
was  cut  direct.  The  posterior  third  of  the  middle  turbinate  re- 
mained in  situ,  apparently  no  sphenoidal  post-ethmoidal  sur- 
gery was  done.  The  surgeon  seems  to  have  lost  his  way,  prob- 
ably under  ether,  combined  mth  blood.  I  say  that  it  was 
probably  a  direct  cut  of  the  optic  nerve  liecause  five  times  in 
my  own  experience  it  has  happened  that  the  capsule  of  the 
ethmoid  or  tlie  body  of  the  sphenoid  has  sustained  some  small 
injury  wliich  has  resulted  in  orl)ital  hemorrhage,  four  of  these 


CASE    HISTORIES  -253 

cases  slioAved  a  small  ecchymosis,  one  of  them,  however,  was 
accompanied  by  great  exophthalnms.  The  condition  subsided 
in  three  days  witli  no  impairment  of  vision  and  no  fanlt  in  any 
wise  found  to  be  with  the  resnlt.  Twenty-two  times  I  have  had 
orbital  phlegmons  to  treat,  twelve  of  which  have  been  back 
of  the  transverse  meridian  with  great  swelling  and  high  grade 
exophthalnms.  In  none  of  tliese  cases  was  there  any  loss  of 
vision.    The  results  gave  a  perfect  eye. 

Orbital  Phlegmon 

T.  C,  age  22  years,  consulted  me  Dec.  10,  1899.  He  gave 
the  history  of  great  pain  reaching  between  his  eyes.  He  was 
examined  2  weeks  before  by  a  rhinologist  and  the  nose  declared 
to  be  negative.  The  pain  continued,  later  it  ceased  suddenly 
and  was  at  once  followed  by  swelling  in  the  eye  socket.  The 
swelling  continued  to  increase,  his  temperature  rose  to  104° 
and  Avhen  I  saw  him  he  was  a  very  desperately  ill  man.  Effort 
was  made  to  drain  the  eye  socket  from  without  but  it  was  not 
satisfactory.  Four  days  later  his  condition  becoming  rapidly 
worse,  (he  was  apparently  moribund)  it  was  determined  that 
the  orbit  should  be  drained  into  the  nose.  I  removed  the  mid- 
dle turbinate  A\ith  the  small  angle  knife,  not  stopping  to  take 
it  out,  I  threw  it  doAMi  into  the  lower  half  of  the  nose  and  pro- 
ceeded rapidly  through  the  posterior  portion  of  the  ethmoidal 
capsule,  making  an  opening  the  size  of  a  man's  little  finger 
into  the  orbit.  In  twenty-four  hours  his  temperature  began  to 
decline  and  in  forty-eight  hours  the  swelling  of  his  orbit  also 
seemed  less.  The  case  made  a  total  recovery.  At  the  time  of 
the  orbital  opening  the  external  erectus  was  apparently  caught 
in  the  inflammatory  trouble  in  such  a  way  that  it  did  not  woi'k. 
Whether  that  were  a  catching  of  the  muscle  or  a  disturliance 
of  the  muscle  function  or  whether  it  w^ere  a  gripping  of  the 
abducens  I  do  not  know.  It  took  six  months  to  come  back  into 
function  perfectly.  Vision  Avith  this  patient  was  never  at  any 
time  disturbed. 

Optic  Nerve  Involvement  with  Sphenoiditis 

Mrs.  S.  X.,  consulted  me  April  18,  1907,  complaining  of 
lower-half  lieadache   of  the   left   side,   and   nasal   obstruction. 


254 


HEADACHES    AXD    EYE    DISORDERS    OF    NASAL    ORIGIIST 


Nothing'  was  .done  for  lier  more  tlian  tentative  treatment  wliicli 
was  not  satisfactory,  Slie  consnlted  me  from  time  to  time  as  the 
years  passed,  always  declining  oiDerative  i^rocedure.  During 
these  years  she  also  suffered  slow  but  constant  failing  of  vision 
in  the  left  eye,  until  it  finally  became  23,  96.  The  right  eye  was 
normal.  She  finally  realized  something  must  be  done  in  effort  to 
save  the  vision  of  her  left  eye;  and  consented  to  the  post-ethmoi- 
dal-sphenoidal  operation. 


%..l7t. 


^tiZ<f^//^ 


9l2t^f^^^^^  /-t  <^^0 


Fis.  ii: 


Very  much  to  my  surprise  the  result  in  this  case  has  been 
a  recovery  of  vision  as  well  as  the  relief  of  headache.  Her  vi- 
sion in  the  left  eye  became  normal  at  the  end  of  three  months. 

It  is  difficult  to  understand  what  may  be  the  process  in  the 
optic  canal  that  can,  as  a  result  of  the  sphenoiditis,  slowly 
diminish  vision  to  such  an  extent  over  a  period  of  nine  years 
and  then  recover  at  the  end  of  three  months,  after  the  sphenoid 
is  opened,  permitting  applications  of  carbolized  oil  within  it. 


CASE    HISTORIES 


255 


I  liave  frequently  seen  in  this  class  of  cases  patients  that  ap- 
pear as  though  there  were  a  regeneration  of  the  optic  nerve  at 
times. 

The  question  arises  whether  in  this  case  there  conld  not 
have  been  a  regeneration  of  fiber. 

Dr.  Charles,  who  sent  the  case  to  me,  has  snlnnitted  a  fnll 
report  which  I  herewith  attach.  This  has  been  one  of  the  most 
fortmiate  results  of  a  long  experience  witli  such  cases. 


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Fig.   11- 


Mrs.  S.  N.  consulted  me  Oct.  15,  1907,  because  her  eyes 
ached  and  burned  constantly,  and  felt  strained  in  near  work. 
She  also  saw  better  upon  closing  the  left  eye.  Dr.  Sluder  had 
treated  her  "four  or  live"  times  and  had  advised  an  operation. 
Fundi  and  pupils  were  normal.  She  was  given  R.E.  +2  Sph. 
+0.5  cyl.  ax.  horl.  V  =  19  12.  L.E.  +2  Sph.  -0.5  cyl.  ax.  vertl. 
\  =  19/48.     These  glasses  proved  satisfactory  and  I  saw  the 


256 


HEADACHES   Al^B    EYE    DISORDERS    OF    NASAL    ORIGUsT 


patient  no  more  nntil  Feb.  1,  1916,  when  the  left  eye  had  "been 
failing  since  snminer."  (Figs.  112  and  113.)  Feb.  3,  R.E. 
V  =  23/15.  L.E.  V  =  23/60  Vid.  field  and  scotoma.  Feb.  9,  1916, 
with  glasses  R.E.  V  =  23/15.  L.E.  V  =  23/96.  "Seems  to  see 
moving  smoke." 

April  4,  R.E.  V  =  23/15.    L.E.  V  =  23/60  to  23/38. 

The  scotoma  had  disappeared  nnder  Dr.   Binder's   treat- 


H^     ^-SSJ/J 


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Fig.    114. 


ment  by  Feb.  23,  and  the  fields  of  vision  were  mnch  improved 
in  regularity  as  well  as  size. 

The  vision  of  the  left  eye  has  remained  at  23/38  and  when 
the  patient  was  last  seen  in  Oct.,  1917,  she  was  entirely  com- 
fortable. 

The  nerves  and  retinas  remained  normal  in  appearance 
throughout,  the  loss  of  vision,  the  scotoma  and  fields  being 
alone  indicative  of  the  involvement  of  the  nerve. 


CASE    HISTORIES 


257 


Uveitis  mth  Post-ethmoidal  Sphenoiditis 

B.  J.  K.,  referred  to  me  April  27, 1917,  by  Dr.  J.  W.  Charles, 
for  a  very  severe  uveitis  of  six  weeks'  standing,  accompanied 
by  pain  in  the  left  shonlder,  which  had  endured  for  seven  years. 
Examination  showed  a  gray  greenish  spot  in  the  sphenoeth- 
moidal recess,  which  I  took  to  be  the  outlet  of  the  sphenoid  with 
a  small  degree  of  secretion  smeared  within  it.  Applications  of 
carbolized  oil  driven  forcilily  into  the  olfactory  fissure,  were 


HL    ^.sy, 


'■■''■■^'rf 


'^JL  =  ... 


Tcl^^^^^--  /irc^o 


Fig.  U.S. 

followed  by  almost  immediate  improvement.  The  condition 
continued  to  improve  under  this  treatment,  and  finally  recov- 
ered totally.  Dr.  Charles  was  very  much  interested,  and  kept 
elaborate  notes;  and  has  given  me  a  full  report,  wliich  I  here- 
with attach. 

B.  J.  K.,  porter,  41  years  old,  came  April  27,  1917,  hav- 
ing been  taking  (for  5  weeks)  KI  and  sodium  phosi)hate  be- 


258  HEADACHES   A^^D    EYE   DISORDERS    OF    NASAL    ORIGIN 

cause  of  failing  vision  in  his  right  eye  in  Avhich  there  was  also 
great  pain  (too  marked  for  the  degree  of  redness).  The  eth- 
moidal region  of  that  side  was  very  tender.  Bowels  move  reg- 
nlarly.     ^'Digestion  perfect." 

The  left  eye  has  been  defective  and  has  diverged  for  eight 
3'ears.  The  patient  was  "cured  of  iritis  six  months  before  and 
had  a  blood  test  which  was  negative. ' ' 

E.E.V.  =  23/240.  Very  marked  hyalitis  (cyclitis),  so  that 
all  details  of  the  fundus  w^ere  obscured. 

L.E.  with  +1.  cyl.  ax.  horl.  V.  =  23/38.— Large  spot  of  cho- 
roidal atrophy  extending  to  the  optic-disc-margin. 

The  fields  showed  a  decided  narrowing  for  colors  Avith 
R.E.  an  enlargement  of  the  normal  blind  spot. 

Patient  was  given  atropine  and  cocaine  in  oil  in  the  right 
eye. 

April  30,  R.E.  without  correction  Y.  =  23/120,  with  ^1.  Sph. 
V.  =23/60. 

May  5,  Dr.  Buhman  reported  a  negative  Wassermann.  A 
E.  Belton  reports  good  teeth  (x-ray). 

May  7,  R.E.  23/96,  with  +1.  Sph.  +0.5  cyl.  ax.  horl.  V.  =  23/75+. 

Tlie  optic  disc  was  now  seen  to  be  more  blurred  (in  com- 
parison with  blood  vessels)  than  was  to  be  accounted  for  by 
the  muddy  vitreous  alone — iDapilloedema. 

May  15,  R.E.  with  glass  V.  -  23/38.  The  enlargement  of 
the  normal  blind  spot  had  disappeared,  the  fields  beginning  to 
improve. 

June  3,  R.E.  with  glass  V.  =  23/19.  Vitreous  and  disc  much 
clearer. 

Sept.  25,  R.E.  with  glass  V.  =  23/15.  Disc  and  vitreous  nor- 
mal.    No  more  pains.     (Figs.  114  and  115.) 

Jan.  21,  1918,  no  change.     Patient  well. 

Iritis  with  Punctate  Keratitis 

Mrs.  A.  B.  N.,  24  years  old,  was  sent  to  me  April  19,  1917, 
by  Dr.  A.  E.  Ewing  because  of  a  punctate  keratitis  Avith  'iritis" 
that  had  been  going  on  in  the  left  eye  four  years  and  in  the 
right  eye  two  and  one-half  years.  Ophthalmological  treatment 
did  not  control  the  trouble.  A  low  grade  sphenoiditis  with  very 
scant   serous   discharge  was  with  great  difficulty  recognized. 


CASE    HISTORIES  259 

Treatment  of  the  district  lieljoed  for  a  while.  A  coryza  re- 
kindled the  eye  troiiljle  and  it  was  then  nncontrollahle.  The- 
post-ethmoidal-sphenoidal  operation  was  done,  left  April  2,. 
1918,  right  April  29,  1918.  Three  days  after  each  operation, 
each  eye  was  free  of  active  pathological  process. 


AFTERTHOUGHTS 

The  frecpiencj"  of  headache  (all  kinds)  withont  recognizable 
sj'stemic  or  organic  neurological  basis  is  well  knoAm.  The  mys- 
tery of  the  etiology  of  many  eye  lesions  is  also  well  known. 
From  a  very  extensive  experience  with  such  cases  I  am  led  to 
the  belief  that  their  explanation  is  to  be  found  in  the  hyper- 
plastic lesion  of  the  post-ethmoidal-sphenoidal  district,  to  a 
degree  of  frequency  that,  could  it  be  put  into  percentage,  would 
astonish  us  all,  however  familiar  we  may  be  with  such  cases. 
At  the  same  time  it  must  be  clearly  understood  that  I  do  not  at 
all  believe  that  lesion  to  be  the  explanation  of  all  such  cases. 
Furthermore  when  one  becomes  familiar  with  that  lesion  he 
soon  begins  to  wonder  if  there  is  an  adult  in  the  temperate  zone 
free  of  it.  This  is  the  question  Dr.  Wright  raised  in  the  intro- 
duction. I  make  the  positive  statement  that  it  is  clinically  as- 
tonishingly frequent  and  may  often  be  found  without  s^miptoms, 
but  that  there  are  also  others  in  whom  the  lesion  clinically  does 
not  exist,  and  that  these  patients  may  he  found  in  all  years  of 
life  and  both  sexes.  It  therefore  requires  definite  discrimina- 
tion in  selecting  these  cases  for  surgical  interference. 

After  finishing  the  arguments  contained  in  these  pages  the 
question  again  arises,  "Is  there  no  bacteriological  factor  in  the 
hyperplastic  lesion?"  Personally  I  think  there  is,  but  I  have 
been  unable  to  prove  it.  It  may  possibly  be  proven  when  the 
bacteriology  of  the  coryza  is  settled. 

In  recording  cases  I  regret  that  Dr.  Wright's  report  does 
not  accompany  each  one.  However,  from  the  examination  of 
the  large  number  of  cases  presented  to  him,  remembering  the 
clinical  appearances  also,  I  feel  sure  of  the  conclusions  recorded. 

The  bibliographical  references  to  the  combined  lesion  of  eye 
and  nose  disorders  are  very  incomplete.    Almost  countless  arti- 


260  HEADACHES   AND    EYE    DISOEDEKS    OF    NASAL    ORIGIN 

cles  have  appeared  in  our  journals  relative  to  eye  disorders 
secondary  to  nasal  disorders,  within  the  past  thirty  years. 
These  would  make  an  interesting  text  in  themselves.  They  do 
not,  however,  bear  upon  the  problems  of  the  vacuum  frontal 
headache,  the  nasal  ganglion  symptom-complex,  or  hyperplastic 
sphenoiditis.  For  these  reasons  I  have  omitted  this  very 
interesting  sidelight  on  our  subject,  knowing  that  I  may  pos- 
sibly encounter  some  criticism  as  deficient  in  scholarship. 
Should  occasion  ever  present,  I  shall  be  glad  to  consider  these 
references. 


\ 


REFERENCES 

1.  Adamkowitz.     Die  Lelire  vom  Hirncompression.     Wiener 

Sitzungsberichte.    1883. 

2.  Berger,  Emil,    ''Berger  and  Tyrmann:"    Die  Krankheiten 

d.  Keilbeinlioelile  nnd  ilirer  Bezieh.  z.  Erkrankungen  d. 
Sehorganes.  Wiesbaden.  Verlag  von  J.  F.  Bergmann. 
1886.— These  de  Paris.    1900. 

3.  Bliss,  M.  A.    The  Importance  of  the  Paranasal  Sinuses  in 

the  Explanation  of  Pain  in  the  Face,  Head,  Neck,  and 
Shoulders.  Trans.  Am.  Neurol.  Assn.,  1914.  Am.  Jour. 
Med.  Sc,  1914. 

4.  BoYER,  A.     Traite  Complet  d'Anatomie.     Tome  1,  p.  126. 

1803.,  Idem,  Tome  IV,  p.  177. 

5.  Brawley,  Frank  E.    The  Relation  of  Diseases  of  the  Nasal 

Accessory  Sinuses  to  Disease  of  the  Eyes.  Jour.  Am. 
Med.  Assn.,  Vol.  XL VIII,  No.  12.    March  23,  1907. 

6.  BucH,  Max.    Die  Sensibilitaetsverhaeltnisse  des  Sympathi- 

cus  and  Vagus  mit  besonderer  Beruecksichtigung  ihrer 
Schmerzempfindlichkeit  im  Bereich  der  Bauchhoele. 
Arch.  f.  Physiologie.  1901.  pp.  197-221;  St.  Petersb. 
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7.  Caldwell,  C  W.    Diseases  of  the  Accessory  Sinuses  of  the 

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261 


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INDEX 


Acute  post-ethmoidal  blinduess,  2-t5 

Amblyopia,    transitory,   248 

Anaesthesia  in  surgery  of  the  paranasal 
cells,  159 
nerve-trunk,  160 

Anaphrodisiac  effects,  233 

Anatomical  relations  of  the  nasal  gan- 
glion,  61 

Anatomical    relations    of   the    sphenoid, 
97 

Anatomy  of  the  middle  meatus,  35 
of  the  nasal  ganglion,  57 
pathologic,  of  the  process,  17 

Anomalous  anatomical  arrangements  in 
the  sphenoid  body,  142 

Antrum   operation,   Sluder's,   185 

Asthma,  case  of.  210 


B 


Bacteriological  investigation  of  hyper- 
plastic post-ethmoidal  sphenoi- 
ditis.  149 

Blindness,  aclite,  case  of,  236 


Case  histories: 

acute   blindness,   23G 

acute   post-ethmoidal   blindness,   245 

asthma,  210 

blepharospasm  and  lower-half  head- 
ache, 204 

change  to  sympathetic  type  with  an- 
aphrodisiac  effects,  233 

conjunctivitis,  246 

dilated  pupil,  207 

ethmoidal  pain  and  peripheral  nerve- 
trunk  injection,  233 

glaucoma  and  the  nasal  ganglion,  243 

iiigh  grade  hvperplastic  sphenoiditis — 
blindness,  203 

hyperplastic  process  advancing  under 
observation,    202 

hyjierplastic   sphenoiditis,   200 

hyperplastic  sphenoiditis  and  preg- 
nancy,  249 

intrasphenoidal  observation  of  inter- 
est,  225 

iritis,  229 

iritis  with  punctate  keratitis,  258 


Case  histories — Cent  'd. 

lifetime  headache  with  loss  of  vision 
at  54  years  of  age,  249 

lower-half     headache     and     blepharo- 
spasm, 204 

meningitis,   death  from,   240 

nasal   ganglion   injection   failure,   244 

nasal   ganglion    neuralgia,    198 

neck  pain,  249 

operative   disaster,   252 

ophthalmic  migraine,  212,  219 

oplitluilmoplegic   migraine,    212 

ophthalmoplegic  migraine  vertigo,  212 

optic  atrophy,  242 

optic    nerve    involvement   with    sphe- 
noiditis, 253 

optic  neuritis,  221 

orbital  hemorrhage.  232 

orbital  phlegmon,  253 

paralysis  of  accommodation,  210 

paralysis   of   the   troclilearis  with    di- 
lated  pupil,   242 

paresthesia   of  upper  extremity  from 
injection,  231 

photophobia,  230 

profession  cramp,  214 

pupil  and  asthma,  207 

scotoma  scintillans,  221 

simple  ganglion  neuralgia,  199 

simple  sphenoiditis — suppurative,  200 

simple  inflammation,  200 

sphenoidal  headache  with  probably  a 
migraine  added.  242 

sphenoiditis  and  tic  douloureux,  229 

sphenoiditis  with  choroiditis,  238 

sphenoiditis   with   pain   in   the    shoul- 
der blades.   244 

sympathetic   cases,   215 

sympathetic  pain,  246 

supraorbital  and  nasal  ganglion  neu- 
ralgia, 247 

tabes,   232 

tic  douloureux,  227 

transitory  amblyopia,  238,  248 
trigeminal     hypalgesia,     paresthesia, 
hypesthiesia,      pupil      dilated — 
sphenoiditis,   234 

uveitis   with    post-ethmoidal    sphenoi- 
ditis, 237 
vacuum    frontal    headaches.    192 

with   active  hyperplastic  bone  proc- 
ess. 194 


269 


270 


INDEX 


Case   histories — Coiit  'd. 

with   spliciioidal  involvement   later, 
194 
vasomotor  rhinitis,  250 

and   nasal   ganglion,   237 
vernal  hay  fever,  235 
vertigo,   234 
vulgar  migraine,   236 
Cavernous  sinus,  99,  100 
Children,   headaches   and   eye    disorders 

in,  125 
Classification   of   method   of   closure    of 

vacuum   nasal   headaches,   47 
Clinical  picture  of  vacuum  frontal  head- 
ache,  32 
Clinical  relations  of  hyperplastic  sphe- 

noiditis.  111 
Clinical  relations  of  the  nasal  ganglion, 

66 
Conjunctivitis,  case  of,  246 
Correlated     anatomy     of     the     middle 

meatus  of  the  nose,  35 
Coryza  affecting  only  one  part  of  nose, 
147 

D 

Diagnosis    of   hyperplastic   post-ethmoi- 
dal     sphenoiditis    in     children, 
145 
of  hyperplastic  sphenoiditis,   131 
of  nasal  ganglion  neuralgia,  78 
Dilated  puj)il,  case  of,  207 

E 

Epithelium,  oblique  illumination  of,  138 
Ethmoidal  headaches,  vacuum,  56 
Ethmoidal    pain    and   peripheral   nerve- 
trunk  injection,  233 
Ethmoidal  j)Oueh,  38 
Etiology  of  vacuum  frontal  headaches, 

34 
Eustachian   tube,    relation    of,   to    sphe- 
noidal sinus,  119 
Swing's   sign,  32 
Eye   disorder,  explanation   of,   124 
Eye    symptoms,    vacuum    frontal    head- 
ache with,  31 

F 

Forceps,  post-ethmoidal,  178 

G 
Glaucoma  and  the  nasal  ganglion,  243 


H 


Headache  of  nasal  origin,  29 
Headaches: 

and  eye  disorders  in  children,  125 

explanation  of,  124 


Headaches — Cont  'd. 
general,  27 

\acuum    ethmoidal,    with    eye    symp- 
toms only,  56 
vacuum   frontal    {see   Vacuum   frontal 
headaches) 
High  grade  hyperplastic  sphenoiditis — 

blindness,   case   of,  203 
Hvperplasia  of  bone  of  sphenoethmoidal 

wall,  19 
Hyperplastic  post-ethmoiditis,   135 
Hyperplastic    process    advancing    under 

observation,  202 
Hyperplastic  sphenoiditis,  96 
and  pregnancy,  249 
ease  of,  200 

diagnosis  of,  in   children,  145 
Onodi's  observations  on,  119 
prognosis   in,    149 
treatment  of,   152 
unilateral,  significance  of,  141 
Wright 's   observations  on,   117 
Hvpertrophy    of    the   middle   turbinate, 
chronic,  22,  23 


Ivijection  of  the  nasal  ganglion: 
anatomical  considerations  in,  83 
correct  placing  of  the  needle,  85 
instrumentarium  for,  89 
technique  of,  90 

Instrumentarium    for    injection    of   the 
nasal   ganglion,   89 

Intrasphenoidal    observations    of    inter- 
est, 225 

Iritis,  229 

with  punctate  keratitis,  ease  of,  258 


Knife,  sphenoid,  178 
turbinate,  178 


Lifetime   headache   with  loss   of  vision 

at  54  years  of  age,  249 
Light,   source   of,   for  examination,   131 
Lower-half    and    blepharospasm,    cases 
of,  204 


M 


Maxillary  antrum,  no  gravity  drain,  25 

surgery   of,   185 
Meckel 's  ganglion  neurosis,  57 
Megrim,    29 

]\Ieningitis,  death  from,  240 
^Method    of    closure    of    vacuum    nasal 

headaches,   47 
^liddle  meatus,   anatomy  of,  35 
^Middle    turbinate,   68 


INDEX 


271 


Xasal  ganglion: 
anatomy  of,  57 
case,  195 

injection,   failure,    244 
neuralgia,  case  of,   198 
diagnosis  of,  78 
prognosis  of,  79 
treatment  of,  82 
neurosis,   syndrome   of,   57 
relation   of   hyperplastic   sphenoiditis 

to,  96 
relation  of,  to  the  nose,  66 

in  the   sphenomaxillary  fossa,  64 
relation  to  the  walls  of  the  paranasal 

cells,  65 
technique  of  injection  of,  90 
Xasal  lesions  giving  rise  to  headaches, 

29 
Neck  pain,  249 

Nerves,    hyperplastic    sphenoiditis    and 
its  relation  to,  96 
in  the  canals  and  the  sphenoidal  tis- 
sue, clinical  difference  between, 
126 
of  the  nasal  ganglion,  57 
Nerve-trunk  anaesthesia,  160 
Neuralgic    syndrome    with    usual    fore- 
runner, 69 
Neurosis,  nasal   ganglion,   57 
Normal     post-ethmoidal-spheuoidal     dis- 
trict, 133 
Nose,  25-29 

frequent  site  of  intiammatorv  attacks. 

25 
middle  meatus  of  the,  35 
relation  of  the  nasal  ganglion  to  the 
lateral  wall  of,  66 

O 

Oblique  illumination  of  the  epithelium, 
138 

Onodi  's    observations    on    hyperplastic 
sphenoiditis,   119 

Operation,   Binder's   antrum,   185 

Operative  disaster,  252 

Ophthalmic   migraine,    212 
cases  of,  219 

Ophthalmoplegic  migraine  vertigo,  case 
of,  212 

Optic  atrophy,  case  of,  242 

Optic  disorders,  explanation   of.   124 

Optic    nerve    involvement,    with    sphe- 
noiditis, 253 

Optic  neuritis,   case   of,   221 

Orbital  hemorrhage,  cases  of.   232 

Orbital  phlegmon,  case  of,  253 

Osteoblasts,  18 


Palate  hook,  148 

Paralvsis    of    accommodation,    case    of, 
210 


Paralysis  of  tlie  troehlearis  with  di- 
lated pupil,  case  of,  242 

Paranasal   cells,   relations   of   the  nasal 
ganglion  to,  65 
surgery    of,    154 

Paresthesia  of  upper  extremity  from  in- 
jection, 231 

Pathologic  anatomy   of   the  process,   17 

Pathology  of  vacuum  frontal  head- 
aches, 47 

Photophobia,   230 

Polyp  formation  accompanying  hyper- 
plastic i30st-ethmoidal  sphenoi- 
ditis,  136 

Post-ethmoidal    forceps,    178 

Post-ethmoidal-sphenoidal  district,  'nor- 
mal,  133 

Post-ethmoidal-sphenoidal  inflammation 
in  the  young,   128 

Post-operative  results  and  the  external 
skull  in  hvperplastic  sphenoi- 
ditis, 129 

Professional  cramp,  case  of.  214 

Prognosis  in  livperplastic  sphenoiditis, 
149 

Prognosis  of  nasal  ganglion  neuralgia, 
79 

Prognosis  of  vacuum  frontal  headaches, 
54 

Pupil,   209 

and  asthma,  207 

Pus,  transference  of,  140 

E 

Rarefying  osteitis,  21 
Eecord  syringe,  86 

S 

Scotoma  scintillans,  case  of,  221 
Simple  ganglion  neuralgia,  case  of,  199 
Simple  inflammation,  case   of,   200 
Speculum,  sphenoidal,  182 
Sphenoid  body,  anomalies  of,  142 

subdivided,  its  diagnosis,  142,  143 
Sphenoid    cells,    inequality    of,    and   its 

clinical    significance,    145 
Sphenoid   empyemata,  cases   of,   113 
Sphenoid  knife,  178 
Sphenoid,  anatomical  relations  of,  97 

sinus  and  usual  cribriform  plate  with 
their  usual  relations,  181 

district,    101 
Sphenoidal  cell,  no  gravity  drain,  25 
Sj)henoidal    headache   with    jn-obably    a 

migraine  added,  case  of,  242 
Sphenoidal  sinus,  <i2 
Sphenoidal   speculum,  182 
Sphenoiditis: 

and  tie  douloureux,  229 

hyperplastic,     96      (see     Hyperplastic 
sphenoiditis) 

with  choroiditis,  238 


272 


IISTDEX 


Splienoiditis — Coiit  'd- 

with  pain  in  the  shoulder  blades,  241 

suppurative,  ease  of,  200 
Si^henomaxillary  fossa,   Gi 
Sphenopalatine   foramen,   62 
Sphenopalatine   ganglion  neurosis,  57 
Subdivided   sphenoid   body   and   its   di- 
agnosis,  142,  143 
Supraorbital    and    nasal    ganglion    neu- 
ralgia,  247 
Supraorbital  neuralgia,  53 
Surgery  of  the  maxillary  antrum.   185 
Surgery  of   the  paranasal  cells,   154 
Sympathetic   cases,  215 
Sympathetic  pain,   case   of,   246 
Sympathetic  syndrome,   70 

T 

Tabes,   cases  of,   232 

Technique    of    injection    of    the    nasal 

ganglion,  90 
Tic  douloureux,  227 
Transference   of  pus,  140 
Transitory   amblyopia,   case    of,    238 
Treatment      of     hvperplastic      post-eth- 

moidal  splienoiditis,  152 
of  nasal  ganglion  neuralgia,  82 
of  vacuum  frontal  headache,  54 
Trigeminal  hypalgesia,  paresthesia,  hyp- 

esthesia,      pupil      dilated- — sphe- 

noiditis,  234 
Turbinate  knife,  178 


U 

Unilateral  hyperplastic  post-ethmoidal 
splienoiditis,  significance  of, 
140,    141 


Uveitis  with  post-ethmoidal  sphenoiditis, 
case  of,  257 


V 


Vacuum  ethmoidal  headache,  56 
Vacuum  frontal  headache: 

case  of,  193 

clinical  picture  in,  32 

etiology  of,  34 

Ewing's  sign  in,  32 

pathology  of,  147 

prognosis  of,  54 

treatment  of,  54 

with   active,   hyperplastic  bone   proc- 
ess,  194 

with  eye  symptoms  only,  30 

with    sphenoidal    involvement    later, 
194 
Vasomotor  rhinitis  and  nasal  ganglion, 

cases  of,  237 
Vasomotor  rhinitis,  case  of,  250 
Vault  of  the  middle  meatus,  37 
Vernal  hay  fever,  case  of,  235 
Vertigo,  case  of,  234 
Vulgar  migraine,  case  of,  236 


W 


Wiping  action  of  the  soft  palate,  137 
Wright's    observations   on    hyperplastic 
sphenoiditis,  117 


X 


X-ray  in  diagnosis  of  anomalies  of  the 
sphenoid  body,  144 


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